CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
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 343 711.750000 26103.5000 36.6751
Subtotal (Total Children Is Unduplicated) 343 711.750000 26103.5000 36.6751
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 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 2 4.000000 300.0000 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 32 59.000000 4425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.000000 2100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 27.500000 1526.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 39.000000 2925.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 167.000000 11949.7500 71.5554
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Total 878.750000 38053.2500 43.3038
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Number of Children (Unduplicated) With at Least One Service 343
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Center 02
Flag Claims Units Chgs Paid
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R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 919 697.000000 25557.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
98 175.000000 12245.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1022 878.750000 38053.2500 0.0000