CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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 5 4.500000 166.5000 37.0000
Subtotal (Total Children Is Unduplicated) 5 4.500000 166.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.487999 636.6000 75.0000
Subtotal (Total Children Is Unduplicated) 6 8.487999 636.6000 75.0000
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Total 12.987999 803.1000 61.8340
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Number of Children (Unduplicated) With at Least One Service 10
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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 0 0.000000 0.0000 0.0000
P 2 2.487999 186.6000 74.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 225.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 7.500000 391.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15 12.987999 803.1000 74.1000