CMS/EIP Fiscal Report Center: 05
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 225 87.25 3228.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 256 274.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 315 288.25 10665.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 662 2236.75 82722.75 36.98
Subtotal (Total Children Is Unduplicated) 667 2886.25 96616.25 33.47
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 3.00 150.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 12 27.50 1897.26 68.99
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Total 2913.75 98513.51 33.81
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Number of Children (Unduplicated) With at Least One Service 667
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Center 05
Flag Claims Units Chgs Paid
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R 13 13.00 941.12 0.00
U 0 0.00 0.00 0.00
B 1864 972.25 36068.25 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
3370 1928.50 61504.14 0.00
Other 0 0.00 0.00 0.00
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Total 5247 2913.75 98513.51 0.00