CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 41 19.25 712.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 23.25 860.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 177 365.25 13440.25 36.80
Subtotal (Total Children Is Unduplicated) 179 407.75 15012.75 36.82
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 5 17.50 1234.50 70.54
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 5.25 262.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 71.00 3550.00 50.00
INTR-INTR-INTERPRETER 1 1.00 30.00 30.00
OCCT-97530-OT SESSION BY LICENSED OT 1 8.00 543.04 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 13.00 882.44 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.25 356.37 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 3730.00 1865.00 0.50
Subtotal (Total Children Is Unduplicated) 18 3841.25 7876.85 2.05
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Total 4266.50 24124.10 5.65
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Number of Children (Unduplicated) With at Least One Service 183
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Center 01
Flag Claims Units Chgs Paid
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R 12 7.00 259.00 0.00
U 0 0.00 0.00 0.00
B 250 211.25 7742.25 0.00
P 71 2095.00 2176.73 2176.73
D 10 9.25 513.25 0.00
S 117 74.00 2738.00 0.00
H 0 0.00 0.00 0.00
T 39 1331.00 1284.20 1284.20
202 244.75 7853.01 50.00
Other 17 294.25 1557.66 0.00
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Total 718 4266.50 24124.10 3510.93