CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 643 392.25 14513.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 338 339.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 21.75 804.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1436 5473.00 202501.00 37.00
Subtotal (Total Children Is Unduplicated) 1456 6226.00 217819.00 34.99
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 47 47.50 2375.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 80 72.00 3600.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 33.50 2512.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 19.50 1082.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 37.00 2775.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 59.50 4462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 178.00 9879.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 134.00 10050.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 106 106.00 19610.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 24 24.00 2520.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 415 735.50 60856.25 82.74
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 3.00 150.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 289 292.00 2336.00 8.00
Subtotal (Total Children Is Unduplicated) 292 295.00 2486.00 8.43
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Total 7256.50 281161.25 38.75
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Number of Children (Unduplicated) With at Least One Service 1458
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Center 04
Flag Claims Units Chgs Paid
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R 283 303.25 11974.25 0.00
U 0 0.00 0.00 0.00
B 1704 1742.25 71514.00 0.00
P 1910 1966.75 72992.75 73239.62
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
4088 3243.00 124634.00 0.00
Other 0 0.00 0.00 0.00
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Total 7986 7256.50 281161.25 73239.62