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
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 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 794 2127.25 78708.25 37.00
TCON-TCON-TRANSITION CONFERENCE 30 31.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1515 4178.00 143745.00 34.41
----------------------------------------------------------------------------------------------------------------
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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.00 1554.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 170.00 12712.50 74.78
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 0.75 37.50 50.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 73 221.75 15492.90 69.87
----------------------------------------------------------------------------------------------------------------
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
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 55 3242.00 1613.50 0.50
Subtotal (Total Children Is Unduplicated) 71 3253.25 2176.00 0.67
----------------------------------------------------------------------------------------------------------------
Total 7653.00 161413.90 21.09
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1518
----------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
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 39 18.25 675.25 0.00
S 1 2.00 74.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8261 7632.75 160664.65 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8301 7653.00 161413.90 0.00