CMS/EIP Fiscal Report Center: 57
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 10 7.250000 268.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 38.750000 1433.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 87 434.250000 16067.2500 37.0000
Subtotal (Total Children Is Unduplicated) 87 480.250000 17769.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 64.000000 4800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 103.000000 5716.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.000000 975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 73 196.000000 12495.2500 63.7513
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 550.000000 377.0000 0.6855
Subtotal (Total Children Is Unduplicated) 5 551.000000 444.8800 0.8074
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Total 1227.250000 30709.3800 25.0229
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Number of Children (Unduplicated) With at Least One Service 88
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Center 57
Flag Claims Units Chgs Paid
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R 8 13.250000 490.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 182 222.000000 10226.5000 0.0000
P 60 84.250000 3117.2500 3117.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 11 550.000000 377.0000 377.0000
294 357.750000 16498.3800 67.8800
Other 0 0.000000 0.0000 0.0000
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Total 555 1227.250000 30709.3800 3562.1300