CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 658 366.25 13551.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 349 349.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 31.75 1174.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1443 5852.50 216542.50 37.00
Subtotal (Total Children Is Unduplicated) 1457 6599.50 231268.50 35.04
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 44 42.00 2100.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 52 48.50 2425.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 43.00 3225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 45.50 2525.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 36.50 2737.50 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 62 47.00 3525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 156.50 8685.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 142 132.00 9900.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 109 109.00 20165.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 35 35.00 3675.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 399 720.50 61334.50 85.13
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 19.00 950.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 288 296.00 2368.00 8.00
Subtotal (Total Children Is Unduplicated) 293 315.00 3318.00 10.53
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Total 7635.00 295921.00 38.76
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Number of Children (Unduplicated) With at Least One Service 1459
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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 1504 1519.00 63511.50 0.00
P 2760 2706.25 103361.50 102602.31
D 145 148.25 5485.25 5485.25
S 0 0.00 0.00 0.00
H 1 5.00 250.00 250.00
T 0 0.00 0.00 0.00
4253 3256.50 123312.75 0.00
Other 0 0.00 0.00 0.00
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Total 8663 7635.00 295921.00 108337.56