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: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 402 616.250000 22486.7500 36.4897
Subtotal (Total Children Is Unduplicated) 402 616.250000 22486.7500 36.4897
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 51 177.000000 12261.0000 69.2712
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Total 793.250000 34747.7500 43.8043
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Number of Children (Unduplicated) With at Least One Service 402
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Center 02
Flag Claims Units Chgs Paid
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R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 982 614.500000 22422.0000 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
97 178.250000 12307.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1081 793.250000 34747.7500 0.0000