CMS/EIP Fiscal Report Center: 55
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 20 9.000000 333.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 42 48.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 15 8.000000 296.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 406.750000 14856.0000 36.5237
Subtotal (Total Children Is Unduplicated) 77 471.750000 15485.0000 32.8246
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Screening, Eval, and Assessment,Class #02
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 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 74.500000 5587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 50.500000 3787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 39.000000 2925.0000 75.0000
Subtotal (Total Children Is Unduplicated) 58 193.000000 14358.0000 74.3938
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Total 664.750000 29843.0000 44.8936
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Number of Children (Unduplicated) With at Least One Service 77
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Center 55
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 15 16.500000 610.5000 0.0000
P 268 331.525800 14313.6800 14313.6800
D 3 4.500000 337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 10 17.000000 1275.0000 1275.0000
262 293.724200 13193.8200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 559 664.750000 29843.0000 15588.6800