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
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 464 278.500000 10304.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 325 327.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 7.500000 277.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1362 5636.250000 208512.2500 36.9949
Subtotal (Total Children Is Unduplicated) 1387 6249.250000 219094.2500 35.0593
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 46 41.500000 2075.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 67 62.500000 3125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 24.500000 1837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 43.000000 2386.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 48.500000 3637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 225 206.500000 11460.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 87.000000 6525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 115 115.000000 20841.5000 181.2304
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 25 25.000000 2542.1400 101.6856
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.000000 630.5000 48.5000
Subtotal (Total Children Is Unduplicated) 392 710.500000 58361.3900 82.1413
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 272 278.000000 2224.0000 8.0000
Subtotal (Total Children Is Unduplicated) 272 278.000000 2224.0000 8.0000
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Total 7237.750000 279679.6400 38.6418
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Number of Children (Unduplicated) With at Least One Service 1389
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1968 2289.250000 86193.2500 0.0000
P 2032 2113.250000 90806.2500 87531.3500
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3297 2808.500000 101652.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7321 7237.750000 279679.6400 87679.3500