CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 725 2273.500000 84119.5000 37.0000
Subtotal (Total Children Is Unduplicated) 725 2273.500000 84119.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 108.500000 8137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 131 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 91.000000 6825.0000 75.0000
Subtotal (Total Children Is Unduplicated) 156 401.500000 26583.0000 66.2092
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Total 2675.000000 110702.5000 41.3841
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Number of Children (Unduplicated) With at Least One Service 728
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Center 57
Flag Claims Units Chgs Paid
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R 33 22.500000 832.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1710 1355.250000 55035.5000 0.0000
P 1308 1297.250000 54834.5000 54788.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3051 2675.000000 110702.5000 54788.2500