CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1626 1822.75 67441.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1269 1349.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 207 134.25 4931.25 36.73
TCM-T1017TL-TARGETED CASE MANAGEMENT 1147 7970.50 294899.25 37.00
Subtotal (Total Children Is Unduplicated) 2103 11276.5 367272.25 32.57
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 137 139.00 6950.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 146 139.50 6975.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 40 33.00 2475.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 10.50 787.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 132 170.50 12787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 127 135.50 7520.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 156.50 11737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 91.50 6862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 503 528.50 29331.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 497 557.00 41775.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 107 108.00 19980.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 33 33.00 3465.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 1146 2138.00 153885.00 71.98
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 6.00 440.52 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 135.25 6762.50 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 1043 1192.00 8221.50 6.90
Subtotal (Total Children Is Unduplicated) 1072 1333.25 15424.52 11.57
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Total 14747.75 536581.77 36.38
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Number of Children (Unduplicated) With at Least One Service 2123
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Center 04
Flag Claims Units Chgs Paid
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R 19 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1 0.25 9.25 9.25
D 780 795.00 42950.00 22070.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18635 13934.75 492965.77 0.00
Other 0 0.00 0.00 0.00
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Total 19435 14747.75 536581.77 22079.75