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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 202 107.250000 3931.2500 36.6550
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 259 342.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 53 40.750000 1507.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 206 606.750000 22348.0000 36.8323
TCON-TCON-TRANSITION CONFERENCE 18 19.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 443 1115.750000 27787.0000 24.9043
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 6.000000 750.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 20.012001 1500.9000 75.0000
Subtotal (Total Children Is Unduplicated) 21 32.012001 2604.9000 81.3726
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 67.000000 3350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 9 67.000000 3350.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 1214.762001 33741.9000 27.7766
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 444
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 33 31.750000 1630.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1466 1183.012001 32111.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1499 1214.762001 33741.9000 0.0000