CMS/EIP Fiscal Report Center: 55
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 402 1192.250000 43761.7500 36.7052
Subtotal (Total Children Is Unduplicated) 402 1192.250000 43761.7500 36.7052
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 55.000000 4125.0000 75.0000
Subtotal (Total Children Is Unduplicated) 39 58.500000 4487.5000 76.7094
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 48.000000 2400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7 48.000000 2400.0000 50.0000
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Total 1298.750000 50649.2500 38.9985
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Number of Children (Unduplicated) With at Least One Service 402
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Center 55
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 13 14.000000 490.2500 0.0000
P 1294 1225.000000 47148.2500 47148.2500
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
60 59.750000 3010.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1367 1298.750000 50649.2500 47148.2500