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
Agency Filter:EIP DEI DEIP
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 795 1012.500000 37462.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 373 373.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 10.750000 397.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1449 5496.750000 203280.0000 36.9819
Subtotal (Total Children Is Unduplicated) 1508 6893.000000 241140.2500 34.9834
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 61 60.500000 3025.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 99 89.500000 4475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 28.000000 2100.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 34.500000 2587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 58.500000 4387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 202.500000 11238.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 153 150.500000 11287.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.000000 54.4400 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 115 115.000000 11164.5200 97.0828
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 591.8100 147.9525
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 5 5.000000 115.6900 23.1380
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 34 34.000000 2125.0300 62.5009
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 474 838.000000 56451.7400 67.3648
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 365 377.000000 3016.0000 8.0000
Subtotal (Total Children Is Unduplicated) 365 377.000000 3016.0000 8.0000
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Total 8108.000000 300607.9900 37.0755
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Number of Children (Unduplicated) With at Least One Service 1516
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Center 04
Flag Claims Units Chgs Paid
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R 22 20.500000 1328.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1584 1988.000000 75776.7500 0.0000
P 1779 2203.250000 86387.4900 87939.0500
D 55 69.000000 2553.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4071 3819.750000 134284.7500 0.0000
Other 5 6.250000 231.2500 0.0000
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Total 7518 8108.000000 300607.9900 87939.0500