CMS/EIP Fiscal Report Center: 07
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 984 844.25 31209.50 36.97
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 392 413.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 543 746.75 27620.50 36.99
TCM-T1017TL-TARGETED CASE MANAGEMENT 737 2236.50 82639.75 36.95
TCON-TCON-TRANSITION CONFERENCE 55 55.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1356 4295.50 141469.75 32.93
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 9 26.00 1300.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 55.00 3052.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 90 266.50 19950.00 74.86
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.00 50.00 50.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 11 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 114 376.50 25942.84 68.91
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 7.00 350.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 88 5912.00 2956.00 0.50
Subtotal (Total Children Is Unduplicated) 102 5919.25 3318.50 0.56
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Total 10591.25 170731.09 16.12
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Number of Children (Unduplicated) With at Least One Service 1357
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Center 07
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 5 4.75 288.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8070 10586.50 170442.34 0.00
Other 0 0.00 0.00 0.00
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Total 8075 10591.25 170731.09 0.00