CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 72 93.000000 3441.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 95 95.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 129 563.750000 20858.7500 37.0000
Subtotal (Total Children Is Unduplicated) 133 751.750000 24299.7500 32.3242
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 12.000000 900.0000 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 30 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 85 69.000000 3829.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 25.500000 1912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 3647.5100 101.3197
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 32.5600 32.5600
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 95 170.000000 12168.8200 71.5813
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 17.000000 850.0000 50.0000
TRAN-TRAN-FAMILY TRANSPORTATION 73 78.000000 624.0000 8.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 2 340.000000 170.0000 0.5000
Subtotal (Total Children Is Unduplicated) 74 435.000000 1644.0000 3.7793
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Total 1356.750000 38112.5700 28.0911
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Number of Children (Unduplicated) With at Least One Service 133
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Center 04
Flag Claims Units Chgs Paid
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R 2 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 97 150.250000 5850.0000 0.0000
P 121 509.750000 7630.4800 8292.9000
D 1 0.500000 37.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 13.000000 650.0000 450.0000
T 0 0.000000 0.0000 0.0000
635 681.500000 23879.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 859 1356.750000 38112.5700 8742.9000