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: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 45 38.500000 1424.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 121 121.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 140 769.250000 28462.2500 37.0000
Subtotal (Total Children Is Unduplicated) 144 928.750000 29886.7500 32.1795
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 89.500000 4967.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 41.000000 3075.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 59 59.000000 6856.0700 116.2046
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 122 236.000000 18233.8200 77.2619
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 92 96.000000 768.0000 8.0000
Subtotal (Total Children Is Unduplicated) 92 96.000000 768.0000 8.0000
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Total 1260.750000 48888.5700 38.7774
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Number of Children (Unduplicated) With at Least One Service 144
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Center 04
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 66 113.000000 4509.7500 0.0000
P 190 320.750000 12687.8800 12773.8100
D 2 3.000000 111.0000 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
704 824.000000 31579.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 962 1260.750000 48888.5700 12773.8100