CMS/EIP Fiscal Report Center: 07
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 1201 881.25 32606.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 255 262.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 631 876.50 32430.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1606 4845.75 179172.50 36.98
TCON-TCON-TRANSITION CONFERENCE 30 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1710 6896.50 244209.25 35.41
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 4.00 125.00 31.25
EXIT-EXIT-TRANSITION ASSESSMENT 3 4.00 200.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 14.00 1050.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 75.00 4162.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 364.50 27225.00 74.69
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 46 47.00 2350.00 50.00
Subtotal (Total Children Is Unduplicated) 176 520.25 35881.46 68.97
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 8.25 412.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 55 3242.00 1613.50 0.50
Subtotal (Total Children Is Unduplicated) 74 3256.25 2326.00 0.71
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Total 10673.00 282416.71 26.46
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Number of Children (Unduplicated) With at Least One Service 1710
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Center 07
Flag Claims Units Chgs Paid
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R 232 148.00 5476.00 0.00
U 0 0.00 0.00 0.00
B 4023 2618.75 105840.31 0.00
P 346 200.00 7374.25 7374.25
D 39 18.25 675.25 0.00
S 6 7.25 268.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8324 7680.75 162782.65 0.00
Other 0 0.00 0.00 0.00
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Total 12970 10673.00 282416.71 7374.25