CMS/EIP Fiscal Report Center: 05
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 259 101.50 3755.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 273 316.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 338 311.75 11534.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 689 2368.25 87616.00 37.00
Subtotal (Total Children Is Unduplicated) 695 3097.50 102906.25 33.22
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 100.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 9 9.00 655.02 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 12 28.00 1905.17 68.04
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.75 237.50 50.00
Subtotal (Total Children Is Unduplicated) 1 4.75 237.50 50.00
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Total 3130.25 105048.92 33.56
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Number of Children (Unduplicated) With at Least One Service 695
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Center 05
Flag Claims Units Chgs Paid
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R 19 19.00 1264.05 0.00
U 0 0.00 0.00 0.00
B 1907 1002.00 37074.00 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
3635 2109.25 66710.87 0.00
Other 0 0.00 0.00 0.00
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Total 5561 3130.25 105048.92 0.00