CMS/EIP Fiscal Report Center: 55
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 497 1503.000000 55361.0000 36.8337
Subtotal (Total Children Is Unduplicated) 497 1503.000000 55361.0000 36.8337
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 74.500000 5587.5000 75.0000
Subtotal (Total Children Is Unduplicated) 53 80.500000 6008.2500 74.6366
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 40.500000 2025.0000 50.0000
Subtotal (Total Children Is Unduplicated) 8 40.500000 2025.0000 50.0000
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Total 1624.000000 63394.2500 39.0359
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Number of Children (Unduplicated) With at Least One Service 497
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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 39 41.500000 1535.5000 0.0000
P 1631 1534.000000 59537.7500 59537.7500
D 0 0.000000 0.0000 0.0000
S 4 3.500000 129.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 45.000000 2191.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1724 1624.000000 63394.2500 59537.7500