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: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 15 12.250000 453.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 8 9.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 28.000000 1036.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 104.000000 3848.0000 37.0000
Subtotal (Total Children Is Unduplicated) 26 153.250000 5337.2500 34.8271
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 30.500000 1692.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 35.000000 2625.0000 75.0000
Subtotal (Total Children Is Unduplicated) 21 71.000000 4691.2500 66.0739
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 21 1981.000000 990.5000 0.5000
Subtotal (Total Children Is Unduplicated) 21 1981.000000 990.5000 0.5000
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Total 2205.250000 11019.0000 4.9967
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Number of Children (Unduplicated) With at Least One Service 26
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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 94 114.750000 4984.0000 4984.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 125 2055.500000 3564.0000 3564.0000
T 0 0.000000 0.0000 0.0000
18 35.000000 2471.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 237 2205.250000 11019.0000 8548.0000