CMS/EIP Fiscal Report Center: 52
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 45 25.000000 925.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 41.500000 1535.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 83 315.500000 11673.5000 37.0000
Subtotal (Total Children Is Unduplicated) 85 382.000000 14134.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 50.0000 25.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 5 9.500000 250.0000 26.3158
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 66.500000 4987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 26.500000 1987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 78.500000 4356.7500 55.5000
Subtotal (Total Children Is Unduplicated) 55 213.500000 13812.0000 64.6932
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 45 2571.000000 1285.5000 0.5000
Subtotal (Total Children Is Unduplicated) 45 2571.000000 1285.5000 0.5000
-----------------------------------------------------------------------------------------------------------------------
Total 3166.500000 29231.5000 9.2315
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 85
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 57 60.750000 3403.2500 0.0000
P 202 420.500000 9534.0000 9534.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 28.000000 1963.5000 0.0000
T 0 0.000000 0.0000 0.0000
440 2657.250000 14330.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 714 3166.500000 29231.5000 9534.0000