CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
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 801 499.25 18472.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 323 323.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 38 24.00 852.00 35.50
TCM-T1017TL-TARGETED CASE MANAGEMENT 1306 5136.25 190041.25 37.00
Subtotal (Total Children Is Unduplicated) 1340 5982.50 209365.50 35.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 31 31.00 1550.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 42 34.00 1700.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 46.50 3487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 27.00 1498.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 41.00 3075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 43.50 3262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 181 184.00 10212.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 159.50 11962.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 123 123.00 22610.50 183.83
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.00 1650.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 33 33.00 3465.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
Subtotal (Total Children Is Unduplicated) 352 743.50 65683.50 88.34
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 2.50 183.55 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 22.25 1112.50 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 277 290.00 1949.50 6.72
Subtotal (Total Children Is Unduplicated) 283 314.75 3245.55 10.31
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Total 7040.75 278294.55 39.53
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Number of Children (Unduplicated) With at Least One Service 1341
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Center 04
Flag Claims Units Chgs Paid
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R 22 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 3536 3365.75 125635.25 0.00
P 135 120.50 10351.25 10486.03
D 35 36.00 2315.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4811 3470.00 138198.05 0.00
Other 0 0.00 0.00 0.00
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Total 8539 7040.75 278294.55 10486.03