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
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 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 456 1811.50 67025.50 37.00
Subtotal (Total Children Is Unduplicated) 1008 2547.00 80882.00 31.76
----------------------------------------------------------------------------------------------------------------
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 4 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
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 40 35.50 2662.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 20.00 1500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 62.00 3441.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 110.50 8287.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.00 2035.00 185.00
Subtotal (Total Children Is Unduplicated) 319 367.00 24918.50 67.90
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 12.00 600.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 279 282.00 2256.00 8.00
Subtotal (Total Children Is Unduplicated) 284 294.00 2856.00 9.71
----------------------------------------------------------------------------------------------------------------
Total 3208.00 108656.50 33.87
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1027
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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 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
4082 3206.00 108526.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4084 3208.00 108656.50 130.50