CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:11/30/2011 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 44 39.750000 1461.5000 36.7673
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 34 34.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 71 69.250000 2562.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 66.250000 2451.2500 37.0000
Subtotal (Total Children Is Unduplicated) 77 209.250000 6475.0000 30.9438
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 5 19.000000 1347.0000 70.8947
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 2.000000 100.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 48 3880.000000 1940.0000 0.5000
Subtotal (Total Children Is Unduplicated) 48 3882.000000 2040.0000 0.5255
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Total 4110.250000 9862.0000 2.3994
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Number of Children (Unduplicated) With at Least One Service 79
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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 0 0.000000 0.0000 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 1 25.000000 12.5000 12.5000
T 123 1160.000000 3167.0000 3167.0000
264 2925.250000 6682.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 388 4110.250000 9862.0000 3179.5000