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
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 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 72 330.750000 12237.7500 37.0000
Subtotal (Total Children Is Unduplicated) 138 490.250000 13662.2500 27.8679
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 15.500000 860.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 26.000000 1950.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 121.5000 40.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 88 68.500000 4599.2500 67.1423
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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 654.750000 19029.5000 29.0638
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Number of Children (Unduplicated) With at Least One Service 138
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
529 651.750000 18918.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 531 654.750000 19029.5000 0.0000