CMS/EIP Fiscal Report Center: 05
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 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
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 47.500000 3562.5000 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) 39 51.500000 3808.0600 73.9429
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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 1505.000000 57600.5600 38.2728
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Number of Children (Unduplicated) With at Least One Service 419
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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
2 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2598 1505.000000 57600.5600 0.0000