CMS/EIP Fiscal Report Center: 05
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 36 16.00 592.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 13 13.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 7.25 268.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 54 153.75 5688.75 37.00
Subtotal (Total Children Is Unduplicated) 54 190.00 6549.00 34.47
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 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 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 15 35.00 2160.51 61.73
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Total 225.00 8709.51 38.71
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Number of Children (Unduplicated) With at Least One Service 54
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Center 05
Flag Claims Units Chgs Paid
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R 16 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 272 148.75 5906.69 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
128 69.00 2534.57 0.00
Other 0 0.00 0.00 0.00
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Total 416 225.00 8709.51 0.00