CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.750000 27.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.250000 83.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 10.250000 379.2500 37.0000
Subtotal (Total Children Is Unduplicated) 3 14.250000 490.2500 34.4035
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 261.0000 65.2500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 70.000000 35.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1 70.000000 35.0000 0.5000
-----------------------------------------------------------------------------------------------------------------------
Total 88.250000 786.2500 8.9093
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3
-----------------------------------------------------------------------------------------------------------------------
Center 53
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 12 12.250000 490.2500 490.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 74.000000 146.0000 146.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 88.250000 786.2500 636.2500