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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 695 2170.500000 80308.5000 37.0000
Subtotal (Total Children Is Unduplicated) 695 2170.500000 80308.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.500000 712.5000 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 7 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 99.000000 7425.0000 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 111 143.000000 7936.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 75.000000 5625.0000 75.0000
Subtotal (Total Children Is Unduplicated) 136 346.000000 22976.2500 66.4053
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Total 2516.500000 103284.7500 41.0430
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Number of Children (Unduplicated) With at Least One Service 698
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Center 57
Flag Claims Units Chgs Paid
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R 31 21.000000 777.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1655 1295.750000 52108.2500 0.0000
P 1231 1197.750000 50249.5000 50203.2500
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
2 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2919 2516.500000 103284.7500 50203.2500