CMS/EIP Fiscal Report Center: 05
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 13 5.250000 194.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 30.500000 1128.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 50 262.250000 9703.2500 37.0000
Subtotal (Total Children Is Unduplicated) 50 299.000000 11026.0000 36.8763
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 114.7500 57.3750
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 189.7500 94.8750
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 29.500000 1377.0000 46.6780
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 11.000000 421.5000 38.3182
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 344.2500 68.8500
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.000000 610.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 41.000000 3687.0000 89.9268
Subtotal (Total Children Is Unduplicated) 35 107.500000 7044.7500 65.5326
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 7.500000 375.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 578.000000 289.0000 0.5000
Subtotal (Total Children Is Unduplicated) 13 585.500000 664.0000 1.1341
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Total 992.000000 18734.7500 18.8858
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Number of Children (Unduplicated) With at Least One Service 51
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Center 05
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 179 150.500000 6157.5000 0.0000
P 21 255.500000 1078.9800 1078.9800
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
291 586.000000 11498.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 491 992.000000 18734.7500 1078.9800