CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 528 1515.750000 56082.7500 37.0000
Subtotal (Total Children Is Unduplicated) 528 1515.750000 56082.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.000000 525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 143.500000 10762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 214.500000 11904.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 60.000000 4500.0000 75.0000
Subtotal (Total Children Is Unduplicated) 152 444.000000 28922.2500 65.1402
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 135.7600 67.8800
Subtotal (Total Children Is Unduplicated) 3 8.000000 435.7600 54.4700
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Total 1967.750000 85440.7600 43.4205
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Number of Children (Unduplicated) With at Least One Service 548
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Center 57
Flag Claims Units Chgs Paid
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R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1113 1044.750000 43463.5000 0.0000
P 825 897.750000 40467.7500 40467.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.750000 495.7500 0.0000
T 0 0.000000 0.0000 0.0000
9 16.500000 976.7600 435.7600
Other 0 0.000000 0.0000 0.0000
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Total 1954 1967.750000 85440.7600 40903.5100