CMS/EIP Fiscal Report Center: 07
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 920 790.25 29220.75 36.98
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 380 393.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 516 706.00 26122.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 709 2018.75 74610.50 36.96
TCON-TCON-TRANSITION CONFERENCE 36 36.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1301 3944.00 129953.25 32.95
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 5 9.00 450.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 51.50 2850.00 55.34
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 214.50 16087.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 11 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 95 292.00 20344.06 69.67
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 4.75 237.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 62 4059.00 1994.50 0.49
Subtotal (Total Children Is Unduplicated) 72 4065.75 2332.00 0.57
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Total 8301.75 152629.31 18.39
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Number of Children (Unduplicated) With at Least One Service 1303
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Center 07
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 1 0.50 18.50 0.00
P 4128 5202.50 91525.31 93708.31
D 60 37.50 1444.50 0.00
S 2 1.00 37.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2744 3060.25 59604.00 0.00
Other 0 0.00 0.00 0.00
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Total 6935 8301.75 152629.31 93708.31