CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 53 19.25 712.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 101 101.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.75 101.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 131 563.00 20831.00 37.00
Subtotal (Total Children Is Unduplicated) 132 686.00 21645.00 31.55
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 24.00 1800.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 67.00 3718.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 45.00 3375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.00 6105.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 101 202.50 17424.75 86.05
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 84 85.00 641.50 7.55
Subtotal (Total Children Is Unduplicated) 84 85.00 641.50 7.55
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Total 973.50 39711.25 40.79
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Number of Children (Unduplicated) With at Least One Service 132
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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 189 255.00 10643.25 0.00
P 53 74.75 3141.75 3248.05
D 5 7.00 259.00 259.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
594 627.75 25334.25 0.00
Other 0 0.00 0.00 0.00
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Total 844 973.50 39711.25 3507.05