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
Payclass Filters:GR
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 38 121.250000 4477.0000 36.9237
Subtotal (Total Children Is Unduplicated) 95 310.750000 10138.0000 32.6243
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 15.666600 1174.9950 75.0000
Subtotal (Total Children Is Unduplicated) 12 33.666600 2251.9950 66.8911
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 67 4706.000000 2353.0000 0.5000
Subtotal (Total Children Is Unduplicated) 67 4707.000000 2403.0000 0.5105
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Total 5051.416600 14792.9950 2.9285
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Number of Children (Unduplicated) With at Least One Service 96
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Center 53
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 144 738.000000 3838.5000 3838.5000
D 5 8.000000 409.0000 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
257 3344.666600 7141.2450 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 543 5051.416600 14792.9950 7242.7500