CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 593 435.25 16104.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 403 412.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 15.25 564.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1409 5591.25 206839.25 36.99
Subtotal (Total Children Is Unduplicated) 1447 6453.75 223507.75 34.63
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 44 43.00 2150.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 61 53.50 2675.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 11.00 825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 42.50 3187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 42.50 2358.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 41.00 3075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 38.00 25.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 84 60.50 4537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 224 210.50 11628.75 55.24
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 171 186.50 13987.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 150 150.00 27750.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 31 31.00 3255.00 105.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 463 900.00 77511.00 86.12
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 321 327.00 2616.00 8.00
Subtotal (Total Children Is Unduplicated) 322 330.00 2789.42 8.45
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Total 7683.75 303808.17 39.54
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Number of Children (Unduplicated) With at Least One Service 1451
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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 1480 1615.00 63942.00 0.00
P 2530 2641.25 112841.00 109238.81
D 69 67.00 2479.00 2479.00
S 1 2.00 74.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3878 3358.50 124472.17 0.00
Other 0 0.00 0.00 0.00
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Total 7958 7683.75 303808.17 111717.81