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
Payclass Filters:GR
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 452 1731.00 64047.00 37.00
Subtotal (Total Children Is Unduplicated) 1099 2577.25 83371.25 32.35
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 27 27.00 1350.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 42 34.00 1700.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 3.00 225.00 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 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 32.00 2400.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 102 106.50 5910.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 117 128.00 9600.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.00 3330.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
Subtotal (Total Children Is Unduplicated) 294 424.50 30165.75 71.06
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 2.50 183.55 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 19.25 962.50 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 277 290.00 1949.50 6.72
Subtotal (Total Children Is Unduplicated) 282 311.75 3095.55 9.93
----------------------------------------------------------------------------------------------------------------
Total 3313.50 116632.55 35.20
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1108
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 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
4655 3313.50 116632.55 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4655 3313.50 116632.55 0.00