CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 44 28.00 1036.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 14 14.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 95 275.50 10193.50 37.00
Subtotal (Total Children Is Unduplicated) 97 317.50 11229.50 35.37
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 15 21.50 1556.75 72.41
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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 2 16.00 800.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 9 9.00 65.50 7.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 395.00 197.50 0.50
Subtotal (Total Children Is Unduplicated) 11 422.00 1163.00 2.76
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Total 761.00 13949.25 18.33
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Number of Children (Unduplicated) With at Least One Service 97
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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 111 85.75 3259.25 0.00
P 71 448.75 2753.50 2806.33
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 2 8.00 400.00 400.00
T 0 0.00 0.00 0.00
384 217.75 7508.75 0.00
Other 0 0.00 0.00 0.00
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Total 569 761.00 13949.25 3206.33