CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 70 241.250000 8926.2500 37.0000
Subtotal (Total Children Is Unduplicated) 70 241.250000 8926.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 16.500000 1237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 18.500000 1026.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 36 93.000000 6546.0000 70.3871
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 23.000000 1150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 23.000000 1150.0000 50.0000
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Total 357.250000 16622.2500 46.5283
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Number of Children (Unduplicated) With at Least One Service 72
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Center 01
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 97 81.250000 3342.7500 0.0000
P 226 186.500000 7598.5000 7589.2500
D 10 11.000000 407.0000 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
8 25.500000 1318.0000 0.0000
Other 39 52.500000 3937.5000 0.0000
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Total 381 357.250000 16622.2500 7589.2500