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
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 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 12 40.750000 1507.7500 37.0000
Subtotal (Total Children Is Unduplicated) 33 77.000000 2701.0000 35.0779
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.188700 14.1500 74.9868
Subtotal (Total Children Is Unduplicated) 5 11.188700 692.9000 61.9286
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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 2845.188700 4772.4000 1.6774
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Number of Children (Unduplicated) With at Least One Service 33
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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 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 154 2845.188700 4772.4000 4772.4000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 154 2845.188700 4772.4000 4772.4000