CMS/EIP Fiscal Report Center: 04
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 40 21.000000 777.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 144 144.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 108 437.500000 16187.5000 37.0000
Subtotal (Total Children Is Unduplicated) 167 602.500000 16964.5000 28.1568
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 10.500000 787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 41.000000 3075.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 91 68.500000 4963.2500 72.4562
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 91 92.000000 736.0000 8.0000
Subtotal (Total Children Is Unduplicated) 91 92.000000 736.0000 8.0000
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Total 763.000000 22663.7500 29.7035
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Number of Children (Unduplicated) With at Least One Service 167
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Center 04
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
669 763.000000 22663.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 669 763.000000 22663.7500 0.0000