CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 32 19.00 703.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 22.00 814.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 34 55.75 2062.75 37.00
Subtotal (Total Children Is Unduplicated) 73 96.75 3579.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 2 3.00 225.00 75.00
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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 2 12.00 600.00 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) 24 3569.50 3494.53 0.98
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Total 3669.25 7299.28 1.99
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Number of Children (Unduplicated) With at Least One Service 83
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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 79 2363.50 2647.51 2647.51
D 0 0.00 0.00 0.00
S 5 7.25 268.25 0.00
H 0 0.00 0.00 0.00
T 31 1194.00 1064.52 1064.52
172 89.50 3311.50 0.00
Other 1 15.00 7.50 0.00
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Total 288 3669.25 7299.28 3712.03