CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 42 17.000000 629.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 39 35.750000 1322.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 236.250000 8741.2500 37.0000
Subtotal (Total Children Is Unduplicated) 94 289.000000 10693.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 21.500000 1612.5000 75.0000
Subtotal (Total Children Is Unduplicated) 29 55.500000 3918.7500 70.6081
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
INTR-INTR-INTERPRETER 4 6.250000 150.0000 24.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 25 1448.000000 724.0000 0.5000
Subtotal (Total Children Is Unduplicated) 25 1457.250000 1024.0000 0.7027
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Total 1801.750000 15635.7500 8.6781
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Number of Children (Unduplicated) With at Least One Service 99
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Center 01
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 37 1152.000000 2056.7500 2056.7500
D 5 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 13 135.750000 581.0000 581.0000
388 349.500000 12190.5000 0.0000
Other 13 163.000000 752.0000 0.0000
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Total 456 1801.750000 15635.7500 2637.7500