CMS/EIP Fiscal Report Center: 05
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 246 109.25 4042.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 263 264.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 338 325.75 12052.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 688 2237.00 82722.75 36.98
Subtotal (Total Children Is Unduplicated) 693 2936.00 98817.75 33.66
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 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 9 9.00 655.02 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 11 25.00 1680.32 67.21
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Total 2961.00 100498.07 33.94
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Number of Children (Unduplicated) With at Least One Service 693
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Center 05
Flag Claims Units Chgs Paid
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R 42 28.25 1045.25 0.00
U 0 0.00 0.00 0.00
B 1940 1052.50 39275.62 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
3189 1880.25 60177.20 0.00
Other 0 0.00 0.00 0.00
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Total 5171 2961.00 100498.07 0.00