CMS/EIP Fiscal Report Center: 54
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 2 0.750000 27.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 31.500000 1165.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 38 137.500000 5087.5000 37.0000
Subtotal (Total Children Is Unduplicated) 38 173.750000 6280.7500 36.1482
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 31 96.000000 6351.7500 66.1641
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 31 2757.000000 1378.5000 0.5000
Subtotal (Total Children Is Unduplicated) 31 2757.000000 1378.5000 0.5000
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Total 3026.750000 14011.0000 4.6291
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Number of Children (Unduplicated) With at Least One Service 38
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Center 54
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 17 28.250000 1858.7500 0.0000
P 88 94.061300 3557.8500 3557.8200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 154 2845.188700 4772.4000 4772.4000
T 0 0.000000 0.0000 0.0000
41 56.250000 3626.2500 0.0000
Other 2 3.000000 195.7500 0.0000
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Total 302 3026.750000 14011.0000 8330.2200