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:Not Part C
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 55 24.00 888.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 73 73.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 108 494.25 18287.25 37.00
Subtotal (Total Children Is Unduplicated) 109 594.50 19295.50 32.46
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 9.50 712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 49.00 2719.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 28.00 2100.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
Subtotal (Total Children Is Unduplicated) 73 133.00 10740.50 80.76
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 53 53.00 424.00 8.00
Subtotal (Total Children Is Unduplicated) 53 53.00 424.00 8.00
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Total 780.50 30460.00 39.03
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Number of Children (Unduplicated) With at Least One Service 109
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Center 04
Flag Claims Units Chgs Paid
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R 4 4.75 175.75 0.00
U 0 0.00 0.00 0.00
B 161 177.50 8546.00 0.00
P 118 197.75 7908.75 7371.27
D 7 12.00 444.00 18.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
404 388.50 13385.50 0.00
Other 0 0.00 0.00 0.00
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Total 694 780.50 30460.00 7389.77