CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.000000 1500.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 40.500000 2247.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 51.000000 3787.5000 74.2647
Subtotal (Total Children Is Unduplicated) 71 123.000000 8723.5000 70.9228
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 4.500000 225.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 18.000000 900.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 1.000000 0.5000 0.5000
Subtotal (Total Children Is Unduplicated) 7 23.500000 1125.5000 47.8936
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Total 146.500000 9849.0000 67.2287
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Number of Children (Unduplicated) With at Least One Service 74
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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 0 0.000000 0.0000 0.0000
D 73 94.500000 5574.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 40 52.000000 4275.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 113 146.500000 9849.0000 0.0000