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
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 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 21 117.000000 4301.7500 36.7671
Subtotal (Total Children Is Unduplicated) 61 182.000000 4930.7500 27.0920
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 27.793800 2084.5300 74.9998
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.732000 1029.9000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 23 52.025800 3901.9300 74.9999
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Total 234.025800 8832.6800 37.7423
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Number of Children (Unduplicated) With at Least One Service 63
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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 0 0.000000 0.0000 0.0000
P 19 27.525800 2064.4300 2064.4300
D 3 4.500000 337.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 10 17.000000 1275.0000 1275.0000
196 185.000000 5155.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 228 234.025800 8832.6800 3339.4300