CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:GR
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 28 28.50 1054.50 37.00
Subtotal (Total Children Is Unduplicated) 85 61.50 2275.50 37.00
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Screening, Eval, and Assessment,Class #02
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 9 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 12 16.00 1180.50 73.78
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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 1 13.00 650.00 50.00
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) 17 2753.75 2845.77 1.03
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Total 2831.25 6301.77 2.23
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Number of Children (Unduplicated) With at Least One Service 103
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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 0 0.00 0.00 0.00
P 104 2666.75 3398.27 3398.27
D 1 1.00 75.00 0.00
S 7 6.50 240.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
144 151.00 2157.50 0.00
Other 6 6.00 430.50 0.00
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Total 262 2831.25 6301.77 3398.27