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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 962 797.500000 29507.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 56 58.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 567 795.500000 29433.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 509 1507.250000 55768.2500 37.0000
TCON-TCON-TRANSITION CONFERENCE 17 17.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1202 3175.250000 114709.2500 36.1261
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 15 24.750000 1237.5000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 46.500000 2580.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 86.500000 6487.5000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 63 183.250000 11941.0300 65.1625
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.500000 125.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.000000 150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 7 4.000000 100.0000 25.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 64 4156.000000 2063.0000 0.4964
Subtotal (Total Children Is Unduplicated) 72 4165.500000 2438.0000 0.5853
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Total 7524.000000 129088.2800 17.1569
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Number of Children (Unduplicated) With at Least One Service 1204
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Center 07
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
5844 7524.000000 129088.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5844 7524.000000 129088.2800 0.0000