CMS/EIP Fiscal Report Center: 07
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 55 37.75 1396.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 55 84.75 3135.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 114 357.50 13227.50 37.00
Subtotal (Total Children Is Unduplicated) 116 480.00 17760.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.50 862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 46.50 2580.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 109.00 8175.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 55 186.00 12893.25 69.32
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 26 1674.00 837.00 0.50
Subtotal (Total Children Is Unduplicated) 27 1676.00 954.88 0.57
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Total 2342.00 31608.13 13.50
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Number of Children (Unduplicated) With at Least One Service 116
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Center 07
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 42 32.25 1243.25 0.00
P 212 1325.25 11128.38 11128.38
D 0 0.00 0.00 0.00
S 9 7.75 286.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
512 976.75 18949.75 0.00
Other 0 0.00 0.00 0.00
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Total 775 2342.00 31608.13 11128.38