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
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 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 498 1761.50 65175.50 37.00
Subtotal (Total Children Is Unduplicated) 1057 2508.00 80697.00 32.18
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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 11 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 37 38.00 2850.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 19.50 1082.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 19.00 1425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 36 26.50 1987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 92.50 5133.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 99.50 7462.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 306 409.00 27157.00 66.40
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 16.00 800.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 287 302.00 2226.00 7.37
Subtotal (Total Children Is Unduplicated) 291 318.00 3026.00 9.52
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Total 3235.00 110880.00 34.28
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Number of Children (Unduplicated) With at Least One Service 1066
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Center 04
Flag Claims Units Chgs Paid
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R 15 15.50 573.50 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 115 141.25 5226.25 5226.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4084 3078.25 105080.25 0.00
Other 0 0.00 0.00 0.00
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Total 4214 3235.00 110880.00 5226.25