CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 15 7.25 268.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 28 26.50 980.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 172.00 6364.00 37.00
Subtotal (Total Children Is Unduplicated) 39 205.75 7612.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.98 404.00 57.88
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 5 8.00 444.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 16 26.98 1681.78 62.33
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 173.00 86.50 0.50
Subtotal (Total Children Is Unduplicated) 6 173.00 86.50 0.50
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Total 405.73 9381.03 23.12
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Number of Children (Unduplicated) With at Least One Service 39
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Center 05
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 123 81.00 3045.78 0.00
P 16 186.48 900.00 900.00
D 0 0.00 0.00 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
221 138.25 5435.25 0.00
Other 0 0.00 0.00 0.00
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Total 360 405.73 9381.03 900.00