CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.250000 9.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.000000 200.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 61.500000 4575.0000 74.3902
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 31.500000 2325.0000 73.8095
Subtotal (Total Children Is Unduplicated) 49 125.000000 9073.2500 72.5860
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Total 125.250000 9082.5000 72.5150
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Number of Children (Unduplicated) With at Least One Service 50
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Center 55
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 0 0.000000 0.0000 0.0000
P 1 1.500000 112.5000 58.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 25.500000 1912.5000 0.0000
T 0 0.000000 0.0000 0.0000
61 98.250000 7057.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 79 125.250000 9082.5000 58.4100