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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 620 538.500000 19924.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 360 361.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 15.250000 564.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 343 1001.250000 37046.2500 37.0000
Subtotal (Total Children Is Unduplicated) 965 1916.000000 57535.0000 30.0287
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 67 64.500000 3225.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 87 76.500000 3825.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 5.500000 412.5000 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 17 9.500000 712.5000 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 18 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 67.500000 5062.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 182.2600 45.5650
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.000000 388.0000 48.5000
Subtotal (Total Children Is Unduplicated) 332 279.500000 16630.0100 59.4991
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 323 329.000000 2632.0000 8.0000
Subtotal (Total Children Is Unduplicated) 323 329.000000 2632.0000 8.0000
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Total 2524.500000 76797.0100 30.4207
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Number of Children (Unduplicated) With at Least One Service 998
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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 21 27.250000 1008.2500 249.7500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2948 2497.250000 75788.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2969 2524.500000 76797.0100 249.7500