CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 674 395.25 14624.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 325 327.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 41 24.25 897.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1285 4885.75 180772.75 37.00
Subtotal (Total Children Is Unduplicated) 1302 5632.25 196294.25 34.85
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 46 47.50 2375.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 40 39.00 1950.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 8.00 600.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 47.00 3525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 35.00 1942.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 32.50 2437.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 42.00 3150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 169 163.50 9074.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 119.00 8925.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.00 16650.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 43 43.00 4515.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 320.00 160.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 358 687.00 57425.25 83.59
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 20.00 1000.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 287 302.00 2226.00 7.37
Subtotal (Total Children Is Unduplicated) 292 322.00 3226.00 10.02
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Total 6641.25 256945.50 38.69
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Number of Children (Unduplicated) With at Least One Service 1304
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Center 04
Flag Claims Units Chgs Paid
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R 23 28.25 1045.25 0.00
U 0 0.00 0.00 0.00
B 2427 2358.00 90845.75 0.00
P 998 873.25 33900.75 33525.30
D 117 143.00 5304.00 5254.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4238 3238.75 125849.75 0.00
Other 0 0.00 0.00 0.00
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Total 7803 6641.25 256945.50 38779.30