CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 50 32.25 1193.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 14 14.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 99 305.00 11285.00 37.00
Subtotal (Total Children Is Unduplicated) 100 351.25 12478.25 35.53
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 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 1 0.50 37.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 16 17.00 1072.25 63.07
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 28.00 1400.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 6 6.00 48.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 523.00 261.50 0.50
Subtotal (Total Children Is Unduplicated) 9 558.00 1777.38 3.19
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Total 926.25 15327.88 16.55
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Number of Children (Unduplicated) With at Least One Service 100
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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 90 62.25 2416.25 0.00
P 136 632.75 4413.25 4413.25
D 10 8.00 296.00 296.00
S 0 0.00 0.00 0.00
H 7 23.00 1166.38 1166.38
T 0 0.00 0.00 0.00
396 200.25 7036.00 0.00
Other 0 0.00 0.00 0.00
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Total 639 926.25 15327.88 5875.63