CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 739 357.50 13227.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 705 777.75 28776.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2104 6226.25 230288.00 36.99
Subtotal (Total Children Is Unduplicated) 2127 7361.50 272292.25 36.99
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 12.25 612.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 9 20.50 1025.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.50 937.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 90.50 6787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 137.00 7575.75 55.30
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 117.00 8775.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 2.00 114.54 57.27
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 3.00 150.45 50.15
Subtotal (Total Children Is Unduplicated) 184 412.75 27084.49 65.62
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 26.25 1312.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 2.50 125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 47.75 2387.50 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 144.00 72.00 0.50
Subtotal (Total Children Is Unduplicated) 25 220.50 3897.00 17.67
----------------------------------------------------------------------------------------------------------------
Total 7994.75 303273.74 37.93
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2131
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 70 82.50 5203.25 0.00
U 0 0.00 0.00 0.00
B 2036 1410.75 54400.75 0.00
P 1319 950.25 36181.00 36180.50
D 166 206.50 13228.25 0.00
S 1935 1509.00 55833.00 0.00
H 14 22.50 1302.49 0.00
T 0 0.00 0.00 0.00
6236 3806.50 136875.25 0.00
Other 6 6.75 249.75 0.00
-------------------------------------------------
Total 11782 7994.75 303273.74 36180.50