CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:Not Part C
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 32 13.75 508.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 117.25 4338.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 135 565.00 20729.25 36.69
Subtotal (Total Children Is Unduplicated) 135 705.00 25576.25 36.28
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 36.00 2953.13 82.03
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 40.00 2220.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 37.00 3675.02 99.32
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 74 143.00 11042.40 77.22
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 69 3753.00 3190.05 0.85
Subtotal (Total Children Is Unduplicated) 69 3753.00 3190.05 0.85
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Total 4601.00 39808.70 8.65
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Number of Children (Unduplicated) With at Least One Service 138
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Center 54
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 116 103.75 5438.00 0.00
P 415 2945.75 15483.35 14775.58
D 20 15.25 564.25 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
574 1536.25 18323.10 0.00
Other 0 0.00 0.00 0.00
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Total 1125 4601.00 39808.70 14775.58