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
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 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 451 1645.25 60874.25 37.00
Subtotal (Total Children Is Unduplicated) 1041 2398.25 76192.25 31.77
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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 3 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 15.50 1162.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 48.00 2664.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 88.00 6600.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 740.00 185.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 300 326.50 20754.50 63.57
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 289 292.00 2336.00 8.00
Subtotal (Total Children Is Unduplicated) 290 293.00 2386.00 8.14
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Total 3017.75 99332.75 32.92
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Number of Children (Unduplicated) With at Least One Service 1066
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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 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3861 3017.75 99332.75 0.00
Other 0 0.00 0.00 0.00
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Total 3861 3017.75 99332.75 0.00