CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 13 13.000000 481.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 58.250000 2155.2500 37.0000
Subtotal (Total Children Is Unduplicated) 33 76.250000 2636.2500 34.5738
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 2.500000 125.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 280.0000 280.0000
Subtotal (Total Children Is Unduplicated) 5 7.000000 628.5000 89.7857
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.000000 16.0000 8.0000
Subtotal (Total Children Is Unduplicated) 2 2.000000 16.0000 8.0000
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Total 85.250000 3280.7500 38.4839
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Number of Children (Unduplicated) With at Least One Service 33
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Center 04
Flag Claims Units Chgs Paid
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R 2 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8 6.000000 222.0000 0.0000
P 53 36.250000 1341.2500 1341.2500
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
67 40.250000 1615.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 130 85.250000 3280.7500 1341.2500