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
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 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 24 127.250000 4708.2500 37.0000
Subtotal (Total Children Is Unduplicated) 46 164.000000 6031.0000 36.7744
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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 1.000000 39.7500 39.7500
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 114.7500 114.7500
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 15.500000 327.0000 21.0968
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 132.4800 18.9257
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.000000 194.2500 64.7500
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 26.500000 2599.5000 98.0943
Subtotal (Total Children Is Unduplicated) 35 71.000000 4318.2300 60.8201
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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 820.500000 11013.2300 13.4226
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Number of Children (Unduplicated) With at Least One Service 48
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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 0 0.000000 0.0000 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
274 565.000000 9934.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 295 820.500000 11013.2300 1078.9800