CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 32 19.00 703.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 22.00 814.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 132 334.00 12358.00 37.00
Subtotal (Total Children Is Unduplicated) 134 375.00 13875.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 15.00 832.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 20.50 1537.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 30 45.50 3054.50 67.13
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.25 112.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.25 6.25 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.00 150.00 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 9 52.00 2600.00 50.00
INTR-INTR-INTERPRETER 3 5.00 250.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 4.00 271.52 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 22 3537.00 1768.50 0.50
Subtotal (Total Children Is Unduplicated) 26 3609.50 5494.53 1.52
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Total 4030.00 22424.03 5.56
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Number of Children (Unduplicated) With at Least One Service 137
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Center 01
Flag Claims Units Chgs Paid
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R 20 18.00 1149.50 0.00
U 0 0.00 0.00 0.00
B 212 147.50 5971.25 0.00
P 215 2457.75 6347.01 6347.01
D 3 3.00 225.00 0.00
S 83 66.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 31 1194.00 1064.52 1064.52
190 126.75 5117.25 0.00
Other 2 17.00 107.50 0.00
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Total 756 4030.00 22424.03 7411.53