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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 434 718.750000 26251.5000 36.5238
Subtotal (Total Children Is Unduplicated) 434 718.750000 26251.5000 36.5238
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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 4 8.000000 600.0000 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 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 83.000000 6225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.500000 3524.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 36.500000 2737.5000 75.0000
Subtotal (Total Children Is Unduplicated) 67 229.500000 15818.2500 68.9248
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Total 948.250000 42069.7500 44.3657
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Number of Children (Unduplicated) With at Least One Service 434
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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 1097 717.000000 26186.7500 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
128 230.750000 15864.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1227 948.250000 42069.7500 0.0000