CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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 37 24.250000 897.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 33 35.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 69.500000 2571.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 48.500000 1794.5000 37.0000
Subtotal (Total Children Is Unduplicated) 72 177.250000 5263.2500 29.6939
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 10 26.000000 1638.0000 63.0000
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 51 4615.000000 2307.5000 0.5000
Subtotal (Total Children Is Unduplicated) 51 4615.000000 2307.5000 0.5000
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Total 4818.250000 9208.7500 1.9112
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Number of Children (Unduplicated) With at Least One Service 73
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Center 53
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 14 467.000000 382.5000 382.5000
T 146 2441.000000 3923.0000 3923.0000
185 1910.250000 4903.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 345 4818.250000 9208.7500 4305.5000