CMS/EIP Fiscal Report Center: 06
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 15 7.50 277.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 16 16.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 17.25 638.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 183.75 6798.75 37.00
TCON-TCON-TRANSITION CONFERENCE 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 73 227.50 7714.50 33.91
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
Subtotal (Total Children Is Unduplicated) 5 11.50 833.25 72.46
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 17.00 850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 6.50 441.22 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 9.00 599.67 66.63
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 695.00 347.50 0.50
Subtotal (Total Children Is Unduplicated) 9 728.50 2306.27 3.17
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Total 967.50 10854.02 11.22
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Number of Children (Unduplicated) With at Least One Service 73
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Center 06
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 15 9.50 351.50 0.00
P 271 574.00 5462.00 5462.00
D 0 0.00 0.00 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
195 383.50 5022.02 92.50
Other 0 0.00 0.00 0.00
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Total 482 967.50 10854.02 5554.50