CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 611 354.75 13125.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 361 361.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 19.75 730.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1326 5356.00 198172.00 37.00
Subtotal (Total Children Is Unduplicated) 1333 6091.50 212028.50 34.81
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 50 48.00 2400.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 50 48.50 2425.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 8.00 600.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 44 52.50 3937.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 38.50 2136.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 39.00 2925.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 44.00 3300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 181.00 10045.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 150 141.00 10575.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 135.00 135.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 120 120.00 22200.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 50 50.00 5250.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
Subtotal (Total Children Is Unduplicated) 404 789.00 68297.25 86.56
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 31.00 1550.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 279 282.00 2256.00 8.00
Subtotal (Total Children Is Unduplicated) 290 313.00 3806.00 12.16
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Total 7193.50 284131.75 39.50
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Number of Children (Unduplicated) With at Least One Service 1337
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 2877 2863.00 112114.00 0.00
P 952 906.25 35662.50 35760.55
D 2 2.00 130.50 130.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4299 3421.25 136174.75 0.00
Other 0 0.00 0.00 0.00
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Total 8131 7193.50 284131.75 35891.05