CMS/EIP Fiscal Report Center: 53
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 63 61.250000 2247.7500 36.6980
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 36 36.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 90 92.250000 3413.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 95 438.000000 15956.2500 36.4298
Subtotal (Total Children Is Unduplicated) 98 627.500000 21617.2500 34.4498
-----------------------------------------------------------------------------------------------------------------------
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 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 98.000000 5439.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 105.999800 7912.4850 74.6462
Subtotal (Total Children Is Unduplicated) 67 237.999800 15823.4850 66.4853
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 67 4721.000000 2360.5000 0.5000
Subtotal (Total Children Is Unduplicated) 67 4723.000000 2460.5000 0.5210
-----------------------------------------------------------------------------------------------------------------------
Total 5588.499800 39901.2350 7.1399
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 99
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 7.500000 314.5000 0.0000
P 393 1047.500000 16495.0000 16495.0000
D 14 26.000000 1759.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 870.000000 435.0000 435.0000
T 119 90.750000 2969.2500 2969.2500
375 3546.749800 17928.4850 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 926 5588.499800 39901.2350 19899.2500