CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
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 94 42.500000 1572.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 36 25.500000 943.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 139 414.500000 15336.5000 37.0000
Subtotal (Total Children Is Unduplicated) 145 488.500000 17852.5000 36.5455
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 57.9600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 168.6400 21.0800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 53.500000 4012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 58.000000 4350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 31.500000 2362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 93.500000 5189.2500 55.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 92 265.000000 16865.6100 63.6438
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EI Services,Class #03
INTR-INTR-INTERPRETER 2 6.000000 290.0000 48.3333
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 200.000000 100.0000 0.5000
Subtotal (Total Children Is Unduplicated) 5 206.000000 390.0000 1.8932
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Total 959.500000 35108.1100 36.5900
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Number of Children (Unduplicated) With at Least One Service 148
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Center 03
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 9 6.500000 411.5000 0.0000
P 341 295.000000 13714.0000 13717.0000
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 386 262.750000 10721.2500 10721.2500
199 378.250000 10014.0000 0.0000
Other 17 17.000000 247.3600 0.0000
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Total 952 959.500000 35108.1100 24438.2500