CMS/EIP Fiscal Report Center: 54
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 4 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 5.75 212.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 37.50 1387.50 37.00
Subtotal (Total Children Is Unduplicated) 16 47.75 1655.75 34.68
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 3 7.50 477.50 63.67
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.25 152.73 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 263.00 223.55 0.85
Subtotal (Total Children Is Unduplicated) 6 268.25 526.28 1.96
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Total 323.50 2659.53 8.22
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Number of Children (Unduplicated) With at Least One Service 17
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Center 54
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 22 17.25 827.75 0.00
P 55 187.75 1390.18 1390.18
D 1 0.50 18.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
27 118.00 423.10 0.00
Other 0 0.00 0.00 0.00
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Total 105 323.50 2659.53 1390.18