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
Payclass Filters:GR
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 410 1401.000000 51837.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1093 2797.250000 89697.2500 32.0662
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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 3 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 18.000000 1350.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.000000 54.4400 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 84 84.000000 3402.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.000000 36.3400 18.1700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 332.1000 22.1400
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 356 365.500000 18587.6900 50.8555
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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 3539.750000 111300.9400 31.4432
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Number of Children (Unduplicated) With at Least One Service 1137
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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 55 69.000000 2553.0000 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
3711 3470.750000 108747.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3766 3539.750000 111300.9400 0.0000