CMS/EIP Fiscal Report Center: 06
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 13 5.75 212.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 13 13.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 24.75 915.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 66 193.50 7159.50 37.00
Subtotal (Total Children Is Unduplicated) 66 237.00 8288.00 34.97
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.50 637.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.00 825.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 8 20.50 1519.77 74.14
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 35.00 1750.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 11.00 746.68 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 135.76 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 1083.00 541.50 0.50
Subtotal (Total Children Is Unduplicated) 6 1131.00 3173.94 2.81
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Total 1388.50 12981.71 9.35
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Number of Children (Unduplicated) With at Least One Service 67
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Center 06
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 100 74.25 2747.25 37.00
P 141 1153.25 3420.51 3420.51
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
221 161.00 6813.95 92.50
Other 0 0.00 0.00 0.00
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Total 462 1388.50 12981.71 3550.01