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
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 1433 3791.500000 140257.7500 36.9927
Subtotal (Total Children Is Unduplicated) 1433 3791.500000 140257.7500 36.9927
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 16 21.000000 2625.0000 125.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 9.000000 499.5000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 86.000000 4773.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 87 117.500000 8812.5000 75.0000
Subtotal (Total Children Is Unduplicated) 161 250.000000 17947.5000 71.7900
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 65.000000 3250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 17 65.000000 3250.0000 50.0000
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Total 4106.500000 161455.2500 39.3170
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Number of Children (Unduplicated) With at Least One Service 1436
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Center 01
Flag Claims Units Chgs Paid
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R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1439 1011.500000 41104.7500 0.0000
P 3962 3008.250000 115234.7500 115234.7500
D 98 58.500000 2164.5000 0.0000
S 21 24.000000 2775.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.250000 46.2500 0.0000
2 1.000000 56.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5525 4106.500000 161455.2500 115234.7500