CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:DEI Only
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 45 29.00 1073.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 15.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 93 287.75 10646.75 37.00
Subtotal (Total Children Is Unduplicated) 94 331.75 11719.75 35.33
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 7.50 375.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 4.50 337.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 15 20.00 1573.00 78.65
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 1 16.00 400.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 11 11.00 88.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 160.00 80.00 0.50
Subtotal (Total Children Is Unduplicated) 13 195.50 993.00 5.08
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Total 547.25 14285.75 26.10
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Number of Children (Unduplicated) With at Least One Service 95
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Center 04
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 175 112.50 4380.75 0.00
P 48 191.75 1302.50 1302.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 2 7.00 350.00 350.00
T 0 0.00 0.00 0.00
411 236.00 8252.50 0.00
Other 0 0.00 0.00 0.00
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Total 636 547.25 14285.75 1652.50