CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:DEI Only
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 63 21.00 777.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 12.00 444.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 128 187.50 6937.50 37.00
Subtotal (Total Children Is Unduplicated) 153 220.50 8158.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 11.50 825.00 71.74
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 8.50 471.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 27.00 2025.00 75.00
Subtotal (Total Children Is Unduplicated) 26 52.00 3677.25 70.72
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 7.00 350.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 4.00 200.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 32.00 1600.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.75 186.67 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 17 2727.00 1459.10 0.54
Subtotal (Total Children Is Unduplicated) 19 2773.75 3863.65 1.39
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Total 3046.25 15699.40 5.15
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Number of Children (Unduplicated) With at Least One Service 155
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Center 01
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 181 123.00 4720.00 0.00
P 119 2679.25 3860.77 3860.77
D 1 1.00 75.00 0.00
S 47 34.25 1267.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
152 161.00 2693.38 0.00
Other 46 47.75 3083.00 0.00
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Total 546 3046.25 15699.40 3860.77