CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:Not Part C
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 73 49.25 1822.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 53 85.00 3145.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 123 382.25 14134.00 36.98
Subtotal (Total Children Is Unduplicated) 124 516.50 19101.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.00 675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 53.00 2940.50 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 126.00 9450.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 67 212.50 14596.28 68.69
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.00 339.40 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 26 1723.00 861.50 0.50
Subtotal (Total Children Is Unduplicated) 30 1729.50 1275.90 0.74
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Total 2458.50 34973.43 14.23
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Number of Children (Unduplicated) With at Least One Service 125
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Center 07
Flag Claims Units Chgs Paid
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R 3 4.00 224.00 0.00
U 0 0.00 0.00 0.00
B 154 144.75 6281.28 0.00
P 82 677.25 5936.90 5936.90
D 0 0.00 0.00 0.00
S 6 2.75 101.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
607 1629.75 22429.50 0.00
Other 0 0.00 0.00 0.00
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Total 852 2458.50 34973.43 5936.90