CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 114 133.000000 4921.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 131 131.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 161 749.750000 27740.7500 37.0000
Subtotal (Total Children Is Unduplicated) 164 1013.750000 32661.7500 32.2187
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.500000 187.5000 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 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 19.000000 1425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 88.000000 4884.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 82 67.500000 5062.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 14 14.000000 869.4200 62.1014
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 4676.2600 106.2786
Subtotal (Total Children Is Unduplicated) 132 262.500000 19079.4300 72.6835
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 95 100.000000 800.0000 8.0000
Subtotal (Total Children Is Unduplicated) 95 100.000000 800.0000 8.0000
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Total 1376.250000 52541.1800 38.1771
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Number of Children (Unduplicated) With at Least One Service 164
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Center 04
Flag Claims Units Chgs Paid
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R 11 7.000000 525.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 138 246.250000 10008.0000 0.0000
P 175 242.500000 11114.0100 11619.6000
D 1 0.750000 27.7500 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
781 879.750000 30866.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1106 1376.250000 52541.1800 11619.6000