CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 37 32.25 1193.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 104 340.50 12598.50 37.00
Subtotal (Total Children Is Unduplicated) 104 381.75 13791.75 36.13
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 3.50 175.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 3.00 225.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 12 17.00 1633.00 96.06
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 32.00 1600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 3.50 237.58 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 8 8.00 64.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 927.00 463.50 0.50
Subtotal (Total Children Is Unduplicated) 11 972.50 2465.08 2.53
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Total 1371.25 17889.83 13.05
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Number of Children (Unduplicated) With at Least One Service 104
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 77 65.75 2488.25 0.00
P 135 1024.00 4580.20 4311.46
D 3 1.50 55.50 0.00
S 0 0.00 0.00 0.00
H 8 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
455 255.25 9520.25 0.00
Other 0 0.00 0.00 0.00
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Total 679 1371.25 17889.83 5529.34