CMS/EIP Fiscal Report Center: 57
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 44 245.500000 9083.5000 37.0000
Subtotal (Total Children Is Unduplicated) 44 245.500000 9083.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 45.500000 2525.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.500000 712.5000 75.0000
Subtotal (Total Children Is Unduplicated) 35 95.000000 6111.0000 64.3263
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Total 340.500000 15194.5000 44.6241
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Number of Children (Unduplicated) With at Least One Service 44
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Center 57
Flag Claims Units Chgs Paid
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R 8 13.250000 490.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 182 222.000000 10226.5000 0.0000
P 60 84.250000 3117.2500 3117.2500
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
17 21.000000 1360.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 267 340.500000 15194.5000 3117.2500