CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
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 103 686.75 25409.75 37.00
Subtotal (Total Children Is Unduplicated) 137 936.00 32079.00 34.27
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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-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 1 1.00 55.50 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 17 15.00 832.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 21.00 1575.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.00 1850.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 67 95.00 7023.00 73.93
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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 6 27.00 1350.00 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) 47 1206.00 2300.00 1.91
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Total 2237.00 41402.00 18.51
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Number of Children (Unduplicated) With at Least One Service 137
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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 0 0.00 0.00 0.00
P 21 1156.00 1865.00 1865.00
D 89 64.75 3499.75 1332.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1879 1016.25 36037.25 0.00
Other 0 0.00 0.00 0.00
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Total 1989 2237.00 41402.00 3197.00