CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 102.500000 3764.7500 36.7293
Subtotal (Total Children Is Unduplicated) 32 102.500000 3764.7500 36.7293
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 16 52.500000 3557.2500 67.7571
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Total 155.000000 7322.0000 47.2387
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Number of Children (Unduplicated) With at Least One Service 32
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Center 02
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 115 102.500000 3764.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 52.500000 3557.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 146 155.000000 7322.0000 0.0000