CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 108 177.75 6576.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 68 69.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 140 1288.50 47656.00 36.99
Subtotal (Total Children Is Unduplicated) 140 1537.75 54325.25 35.33
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 39 37.25 1862.50 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 18.50 1026.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 26.50 1987.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.00 3515.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.00 420.00 105.00
Subtotal (Total Children Is Unduplicated) 69 117.50 9653.25 82.16
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 50.50 2525.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 44 47.00 285.00 6.06
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 1130.00 565.00 0.50
Subtotal (Total Children Is Unduplicated) 49 1229.50 3475.00 2.83
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Total 2884.75 67453.50 23.38
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Number of Children (Unduplicated) With at Least One Service 140
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 161 119.75 4587.75 0.00
P 754 1655.00 21507.25 21790.57
D 91 66.75 3592.25 1369.00
S 0 0.00 0.00 0.00
H 7 22.00 1100.00 1100.00
T 0 0.00 0.00 0.00
1884 1020.50 36638.50 0.00
Other 0 0.00 0.00 0.00
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Total 2898 2884.75 67453.50 24259.57