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
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 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 17 74.000000 2719.5000 36.7500
Subtotal (Total Children Is Unduplicated) 64 148.250000 3690.7500 24.8954
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 26.563200 1992.2400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.797333 1184.8000 75.0000
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 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 21 53.860533 3961.5400 73.5518
-----------------------------------------------------------------------------------------------------------------------
Total 202.110533 7652.2900 37.8619
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 65
-----------------------------------------------------------------------------------------------------------------------
Center 55
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 18 28.863600 2086.7700 2086.7700
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
184 138.000000 3368.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 228 202.110533 7652.2900 3511.5400