CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Eligibility Filter:Not Part C
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 200 91.75 3394.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 370 376.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 57 35.75 1322.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 403 2622.25 97023.25 37.00
Subtotal (Total Children Is Unduplicated) 403 3125.75 101740.75 32.55
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 10.50 582.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 141 108.50 8137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 73 60.50 4537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 291 283.50 15734.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 201 223.00 16725.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 149 151.00 28030.00 185.63
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 3.00 315.00 105.00
Subtotal (Total Children Is Unduplicated) 375 853.50 75074.50 87.96
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 307 325.00 2322.50 7.15
Subtotal (Total Children Is Unduplicated) 307 325.00 2322.50 7.15
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Total 4304.25 179137.75 41.62
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Number of Children (Unduplicated) With at Least One Service 403
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Center 04
Flag Claims Units Chgs Paid
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R 3 9.00 333.00 0.00
U 0 0.00 0.00 0.00
B 211 284.50 11921.75 0.00
P 884 1215.25 53463.25 52323.01
D 64 72.25 7668.25 1230.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2563 2723.25 105751.50 0.00
Other 0 0.00 0.00 0.00
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Total 3725 4304.25 179137.75 53553.26