CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 43 17.25 638.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 67 50.00 1840.75 36.82
TCM-T1017TL-TARGETED CASE MANAGEMENT 101 336.00 12422.75 36.97
Subtotal (Total Children Is Unduplicated) 101 404.25 14901.75 36.86
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.50 323.50 58.82
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 13 14.50 650.00 44.83
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 51.50 3675.00 71.36
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 17.00 1195.50 70.32
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 52.50 2913.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.50 787.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 66 167.50 10454.50 62.41
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 49 2304.00 1152.00 0.50
Subtotal (Total Children Is Unduplicated) 49 2304.00 1152.00 0.50
----------------------------------------------------------------------------------------------------------------
Total 2875.75 26508.25 9.22
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 102
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 303 258.75 11478.25 0.00
P 4 68.00 133.00 133.00
D 0 0.00 0.00 0.00
S 1 1.00 55.50 0.00
H 9 12.50 918.00 0.00
T 0 0.00 0.00 0.00
473 2535.50 13923.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 790 2875.75 26508.25 133.00