CMS/EIP Fiscal Report Center: 09
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 109 339.000000 12543.0000 37.0000
Subtotal (Total Children Is Unduplicated) 109 339.000000 12543.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 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 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 102.500000 7687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 46.500000 3487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 85 147.000000 8158.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
Subtotal (Total Children Is Unduplicated) 99 348.500000 23202.7500 66.5789
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 7.000000 350.0000 50.0000
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Total 694.500000 36095.7500 51.9737
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Number of Children (Unduplicated) With at Least One Service 119
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Center 09
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 384 626.000000 32182.5000 0.0000
P 35 58.500000 3338.2500 3338.2500
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
5 10.000000 575.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 424 694.500000 36095.7500 3338.2500