CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 61 38.25 1415.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 21 21.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 92 304.25 11238.75 36.94
Subtotal (Total Children Is Unduplicated) 94 364.25 12681.75 34.82
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 14 13.75 687.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 0.75 37.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.50 412.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 21 30.50 2427.00 79.57
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 22.00 1100.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 14 14.00 92.50 6.61
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 555.00 277.50 0.50
Subtotal (Total Children Is Unduplicated) 16 591.00 1470.00 2.49
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Total 985.75 16578.75 16.82
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Number of Children (Unduplicated) With at Least One Service 94
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 192 150.75 5635.25 0.00
P 12 570.50 1335.00 1373.11
D 1 1.00 55.50 0.00
S 0 0.00 0.00 0.00
H 3 9.00 450.00 450.00
T 0 0.00 0.00 0.00
439 254.50 9103.00 0.00
Other 0 0.00 0.00 0.00
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Total 647 985.75 16578.75 1823.11