CMS/EIP Fiscal Report Center: 07
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 78 61.750000 2284.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 78 114.250000 4227.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 295 608.750000 22523.7500 37.0000
Subtotal (Total Children Is Unduplicated) 301 784.750000 29035.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 29.000000 2175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 81.000000 4495.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 114.500000 8587.5000 75.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 68 245.500000 16689.7500 67.9827
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 45 2552.000000 1276.0000 0.5000
Subtotal (Total Children Is Unduplicated) 45 2552.000000 1276.0000 0.5000
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Total 3582.250000 47001.5000 13.1207
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Number of Children (Unduplicated) With at Least One Service 301
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Center 07
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 21 11.000000 407.0000 0.0000
P 418 1594.250000 16085.0000 16085.0000
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
771 1976.500000 30491.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1211 3582.250000 47001.5000 16085.0000