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
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 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 527 1879.75 69550.75 37.00
Subtotal (Total Children Is Unduplicated) 1109 2626.75 84276.75 32.08
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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 4 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 30.00 2250.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 13.00 975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 18.00 1350.00 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 113 91.50 6862.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 294 314.00 20919.50 66.62
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.00 150.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 288 296.00 2368.00 8.00
Subtotal (Total Children Is Unduplicated) 290 299.00 2518.00 8.42
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Total 3239.75 107714.25 33.25
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Number of Children (Unduplicated) With at Least One Service 1124
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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 4 3.50 194.25 484.52
D 142 144.50 5346.50 5346.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4099 3091.75 102173.50 0.00
Other 0 0.00 0.00 0.00
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Total 4245 3239.75 107714.25 5831.02