CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 355 614.750000 22514.5000 36.6238
Subtotal (Total Children Is Unduplicated) 355 614.750000 22514.5000 36.6238
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
Subtotal (Total Children Is Unduplicated) 2 3.000000 166.5000 55.5000
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Total 617.750000 22681.0000 36.7155
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Number of Children (Unduplicated) With at Least One Service 355
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Center 02
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 683 449.250000 16391.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
221 168.500000 6290.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 904 617.750000 22681.0000 0.0000