CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 379 500.750000 18453.7500 36.8522
Subtotal (Total Children Is Unduplicated) 379 500.750000 18453.7500 36.8522
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
Subtotal (Total Children Is Unduplicated) 11 21.500000 1193.2500 55.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 34.000000 1700.0000 50.0000
Subtotal (Total Children Is Unduplicated) 9 34.000000 1700.0000 50.0000
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Total 556.250000 21347.0000 38.3766
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Number of Children (Unduplicated) With at Least One Service 383
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Center 02
Flag Claims Units Chgs Paid
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R 48 28.250000 1082.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 794 526.500000 20209.2500 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
1 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 843 556.250000 21347.0000 0.0000