CMS/EIP Fiscal Report Center: 53
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:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 10.000000 370.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 10.000000 370.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 6.000000 411.0000 68.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 10.000000 500.0000 50.0000
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Total 26.000000 1281.0000 49.2692
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Number of Children (Unduplicated) With at Least One Service 3
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Center 53
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 0 0.000000 0.0000 0.0000
P 13 12.000000 481.0000 481.0000
D 1 2.000000 150.0000 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
11 12.000000 650.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25 26.000000 1281.0000 481.0000