CMS/EIP Fiscal Report Center: 55
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 32 17.250000 638.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 44 48.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 9.000000 333.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 80 411.750000 15197.7500 36.9101
Subtotal (Total Children Is Unduplicated) 80 486.000000 16169.0000 33.2695
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 74.000000 5550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 66.500000 4987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 37.500000 2812.5000 75.0000
Subtotal (Total Children Is Unduplicated) 62 208.000000 15278.2500 73.4531
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Total 694.000000 31447.2500 45.3130
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Number of Children (Unduplicated) With at Least One Service 80
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Center 55
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 20 25.250000 991.2500 0.0000
P 325 370.863600 15862.2700 15862.2700
D 14 16.250000 772.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 12 18.996933 1424.7700 1424.7700
258 262.639467 12396.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 629 694.000000 31447.2500 17287.0400