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
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 182 76.500000 2830.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 319 360.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 315 287.750000 10646.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 691 2438.500000 90196.7500 36.9886
Subtotal (Total Children Is Unduplicated) 694 3162.750000 103674.0000 32.7797
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.000000 30.0000 30.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 47.500000 3562.5000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.000000 145.5600 72.7800
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 40 52.500000 3838.0600 73.1059
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 302.000000 151.0000 0.5000
Subtotal (Total Children Is Unduplicated) 4 306.000000 351.0000 1.1471
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Total 3521.250000 107863.0600 30.6320
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Number of Children (Unduplicated) With at Least One Service 695
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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 2596 1503.500000 57545.0600 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
2693 2017.750000 50318.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5289 3521.250000 107863.0600 0.0000