CMS/EIP Fiscal Report Center: 05
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 414 1452.500000 53742.5000 37.0000
Subtotal (Total Children Is Unduplicated) 414 1452.500000 53742.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 22.500000 1687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.500000 525.0000 70.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.500000 412.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 51.000000 3825.0000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 145.5600 72.7800
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 49 94.000000 6938.5600 73.8145
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 99.500000 4975.0000 50.0000
Subtotal (Total Children Is Unduplicated) 41 102.500000 5050.0000 49.2683
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Total 1649.000000 65731.0600 39.8612
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Number of Children (Unduplicated) With at Least One Service 420
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Center 05
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 2596 1503.500000 57545.0600 0.0000
P 0 0.000000 0.0000 0.0000
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
142 145.500000 8186.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2738 1649.000000 65731.0600 0.0000