CMS/EIP Fiscal Report Center: 06
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 18 66.000000 2442.0000 37.0000
Subtotal (Total Children Is Unduplicated) 18 66.000000 2442.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 10 27.500000 2062.5000 75.0000
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Total 93.500000 4504.5000 48.1765
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Number of Children (Unduplicated) With at Least One Service 18
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Center 06
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 36 38.500000 1424.5000 0.0000
P 25 27.500000 1017.5000 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
20 27.500000 2062.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 81 93.500000 4504.5000 0.0000