CMS/EIP Fiscal Report Center: 54
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 3 0.75 27.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.25 157.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 25.75 952.75 37.00
Subtotal (Total Children Is Unduplicated) 11 35.75 1137.75 31.83
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2 3.00 198.50 66.17
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.25 152.73 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 146.00 124.10 0.85
Subtotal (Total Children Is Unduplicated) 4 150.00 351.83 2.35
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Total 188.75 1688.08 8.94
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Number of Children (Unduplicated) With at Least One Service 11
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Center 54
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 1 2.00 150.00 0.00
P 38 127.25 962.08 962.08
D 6 3.75 138.75 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
22 55.25 418.75 0.00
Other 0 0.00 0.00 0.00
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Total 68 188.75 1688.08 962.08