CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 4.500000 166.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 4.500000 166.5000 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-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 300.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 9.000000 450.0000 50.0000
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Total 17.500000 916.5000 52.3714
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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 1 1.000000 37.0000 0.0000
P 5 5.500000 279.5000 279.5000
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
10 11.000000 600.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 17.500000 916.5000 279.5000