CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
Subtotal (Total Children Is Unduplicated) 10 22.500000 1619.2500 71.9667
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 40.000000 20.0000 0.5000
Subtotal (Total Children Is Unduplicated) 3 40.000000 20.0000 0.5000
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Total 62.500000 1639.2500 26.2280
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Number of Children (Unduplicated) With at Least One Service 13
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Center 52
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 12 22.500000 1619.2500 0.0000
T 0 0.000000 0.0000 0.0000
3 40.000000 20.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15 62.500000 1639.2500 0.0000