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
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 10 7.250000 268.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 38.750000 1433.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 43 188.750000 6983.7500 37.0000
Subtotal (Total Children Is Unduplicated) 67 234.750000 8685.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
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 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 35.500000 2662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 57.500000 3191.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 38 101.000000 6384.2500 63.2104
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 550.000000 377.0000 0.6855
Subtotal (Total Children Is Unduplicated) 5 550.000000 377.0000 0.6855
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Total 885.750000 15447.0000 17.4395
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Number of Children (Unduplicated) With at Least One Service 69
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Center 57
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 0 0.000000 0.0000 0.0000
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
276 335.750000 15070.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 287 885.750000 15447.0000 377.0000