CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:GR
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 49 71.00 2627.00 37.00
Subtotal (Total Children Is Unduplicated) 90 113.50 4199.50 37.00
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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
Subtotal (Total Children Is Unduplicated) 1 3.00 225.00 75.00
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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 2 18.00 900.00 50.00
INTR-INTR-INTERPRETER 1 1.00 30.00 30.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.75 322.43 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 3730.00 1865.00 0.50
Subtotal (Total Children Is Unduplicated) 18 3766.75 3767.43 1.00
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Total 3883.25 8191.93 2.11
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Number of Children (Unduplicated) With at Least One Service 99
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Center 01
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 70 2094.00 2126.73 2126.73
D 0 0.00 0.00 0.00
S 6 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 39 1331.00 1284.20 1284.20
177 180.25 4337.75 0.00
Other 8 274.75 323.00 0.00
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Total 300 3883.25 8191.93 3410.93