CMS/EIP Fiscal Report Center: 05
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 682 392.75 14531.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 746 1355.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 827 1204.50 44566.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 685 4777.00 176702.75 36.99
Subtotal (Total Children Is Unduplicated) 1146 7729.25 235801.00 30.51
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.00 55.50 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
Subtotal (Total Children Is Unduplicated) 5 11.00 773.84 70.35
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.75 37.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.25 62.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.00 150.00 50.00
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Total 7743.25 236724.84 30.57
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Number of Children (Unduplicated) With at Least One Service 1146
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Center 05
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 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 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
13180 7743.25 236724.84 0.00
Other 0 0.00 0.00 0.00
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Total 13180 7743.25 236724.84 0.00