CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 40 21.000000 777.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 144 144.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 181 994.500000 36796.5000 37.0000
Subtotal (Total Children Is Unduplicated) 185 1159.500000 37573.5000 32.4049
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 138 121.500000 6743.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 42.500000 3187.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 53 53.000000 9660.5000 182.2736
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 144 275.000000 23796.2500 86.5318
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 91 92.000000 736.0000 8.0000
Subtotal (Total Children Is Unduplicated) 91 92.000000 736.0000 8.0000
-----------------------------------------------------------------------------------------------------------------------
Total 1526.500000 62105.7500 40.6851
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 185
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 218 307.750000 12260.7500 0.0000
P 278 377.000000 19868.7500 19729.9400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
739 841.750000 29976.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1235 1526.500000 62105.7500 19729.9400