CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 417 227.75 8426.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 421 538.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 315 253.75 9388.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 382 1058.25 38822.25 36.69
TCON-TCON-TRANSITION CONFERENCE 77 77.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 674 2154.75 56637.75 26.29
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 3 3.75 187.50 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 20 32.75 1911.25 58.36
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 29.00 1450.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 13 8.25 412.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.25 31.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 2.75 137.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.50 37.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 70.25 3512.50 50.00
INTR-INTR-INTERPRETER 1 1.50 37.50 25.00
OCCT-97530-OT SESSION BY LICENSED OT 3 21.75 1476.39 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 5.00 339.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 38.25 2596.41 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 246 32523.0 16261.50 0.50
Subtotal (Total Children Is Unduplicated) 246 32704.5 26379.95 0.81
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Total 34892.00 84928.95 2.43
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Number of Children (Unduplicated) With at Least One Service 689
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Center 52
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 1 1.50 101.82 0.00
H 1 1.50 83.25 0.00
T 0 0.00 0.00 0.00
4415 34889.00 84743.88 0.00
Other 0 0.00 0.00 0.00
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Total 4417 34892.00 84928.95 0.00