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
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 30 103.000000 3811.0000 37.0000
Subtotal (Total Children Is Unduplicated) 30 103.000000 3811.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 27.000000 1498.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 17.000000 1275.0000 75.0000
Subtotal (Total Children Is Unduplicated) 21 57.500000 3756.7500 65.3348
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 200.0000 50.0000
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Total 164.500000 7767.7500 47.2204
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Number of Children (Unduplicated) With at Least One Service 30
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Center 57
Flag Claims Units Chgs Paid
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R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 55 59.500000 2927.2500 0.0000
P 77 99.500000 4585.0000 4585.0000
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
2 4.000000 200.0000 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 136 164.500000 7767.7500 4785.0000