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
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 689 2789.500000 103211.5000 37.0000
Subtotal (Total Children Is Unduplicated) 689 2789.500000 103211.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 128.500000 9637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 189.000000 10489.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 136 357.000000 22855.5000 64.0210
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Total 3146.500000 126067.0000 40.0658
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Number of Children (Unduplicated) With at Least One Service 690
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Center 57
Flag Claims Units Chgs Paid
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R 75 75.250000 2784.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1060 1088.500000 48540.2500 0.0000
P 2011 1929.750000 71437.7500 71358.3300
D 1 2.000000 74.0000 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
38 51.000000 3230.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3185 3146.500000 126067.0000 71358.3300