CMS/EIP Fiscal Report Center: 04
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 659 362.00 13394.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 340 340.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 40 28.00 1036.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1433 5823.25 215460.25 37.00
Subtotal (Total Children Is Unduplicated) 1447 6553.25 229890.25 35.08
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 40 38.50 1925.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 56 55.00 2750.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 25.00 1875.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 27.00 1498.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 68.50 5137.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 201 187.50 10406.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 137 140.50 10537.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.00 18685.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.00 2835.00 105.00
Subtotal (Total Children Is Unduplicated) 395 726.50 60687.25 83.53
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 20.00 1000.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 286 286.00 2288.00 8.00
Subtotal (Total Children Is Unduplicated) 297 306.00 3288.00 10.75
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Total 7585.75 293865.50 38.74
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Number of Children (Unduplicated) With at Least One Service 1452
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Center 04
Flag Claims Units Chgs Paid
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R 24 21.00 777.00 0.00
U 0 0.00 0.00 0.00
B 1771 1789.25 73570.75 0.00
P 2256 2248.75 88390.00 85981.94
D 83 79.75 2969.75 786.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4510 3447.00 128158.00 0.00
Other 0 0.00 0.00 0.00
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Total 8644 7585.75 293865.50 86768.19