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
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 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 546 2062.75 76321.75 37.00
Subtotal (Total Children Is Unduplicated) 1106 2792.75 90751.75 32.50
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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 2 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 20.00 1500.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 57.00 3163.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 105.00 7875.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 280 325.00 21208.00 65.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 5.00 250.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 286 286.00 2288.00 8.00
Subtotal (Total Children Is Unduplicated) 290 291.00 2538.00 8.72
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Total 3408.75 114497.75 33.59
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Number of Children (Unduplicated) With at Least One Service 1121
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Center 04
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 82 79.25 2932.25 786.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4386 3329.50 111565.50 0.00
Other 0 0.00 0.00 0.00
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Total 4468 3408.75 114497.75 786.25