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
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 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 75 298.000000 11026.0000 37.0000
Subtotal (Total Children Is Unduplicated) 122 486.000000 14467.0000 29.7675
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 15.500000 1162.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 91.1300 45.5650
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 58 38.000000 2611.3800 68.7205
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 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) 74 422.000000 994.0000 2.3555
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Total 946.000000 18072.3800 19.1040
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Number of Children (Unduplicated) With at Least One Service 123
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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 5 344.000000 370.0000 370.0000
D 1 0.500000 37.5000 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
537 601.500000 17664.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 543 946.000000 18072.3800 370.0000