CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:11/30/2011 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 62 254.250000 9388.7500 36.9272
Subtotal (Total Children Is Unduplicated) 62 254.250000 9388.7500 36.9272
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 61.500000 3413.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 67.500000 5062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 37 145.000000 9636.7500 66.4603
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 400.250000 19075.5000 47.6590
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Number of Children (Unduplicated) With at Least One Service 63
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Center 53
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 10 9.500000 427.5000 0.0000
P 251 294.250000 12501.5000 12501.5000
D 4 8.000000 600.0000 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
54 88.500000 5546.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 319 400.250000 19075.5000 12501.5000