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
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 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 86 327.750000 12126.7500 37.0000
Subtotal (Total Children Is Unduplicated) 156 591.750000 17047.7500 28.8090
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 9.500000 712.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 11 11.000000 299.4200 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.000000 1215.0000 40.5000
Subtotal (Total Children Is Unduplicated) 84 88.000000 4639.6700 52.7235
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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 779.750000 22487.4200 28.8393
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Number of Children (Unduplicated) With at Least One Service 156
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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 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
669 779.000000 22459.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 670 779.750000 22487.4200 0.0000