CMS/EIP Fiscal Report Center: 55
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 26 10.75 397.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 29 32.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 12.25 453.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 80 309.25 11423.75 36.94
Subtotal (Total Children Is Unduplicated) 80 364.25 12274.75 33.70
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 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 31 54.50 4087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 26.50 1987.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 51.00 2830.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 26.00 2125.00 81.73
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 51 175.00 12212.25 69.78
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 36.00 25.60 0.71
Subtotal (Total Children Is Unduplicated) 1 36.00 25.60 0.71
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Total 575.25 24512.60 42.61
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Number of Children (Unduplicated) With at Least One Service 80
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Center 55
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 175 192.70 8364.33 8364.33
D 16 19.25 826.25 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
288 363.30 15322.02 0.00
Other 0 0.00 0.00 0.00
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Total 479 575.25 24512.60 8364.33