CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 23 8.50 314.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 27 28.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 53 43.25 1600.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 200.75 7427.75 37.00
TCON-TCON-TRANSITION CONFERENCE 2 2.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 59 282.50 9342.50 33.07
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 162.72 81.36
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 15 28.00 1554.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 49.50 2747.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.50 1612.50 75.00
Subtotal (Total Children Is Unduplicated) 29 135.00 8548.47 63.32
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 29 2245.00 1122.50 0.50
Subtotal (Total Children Is Unduplicated) 29 2246.00 1147.50 0.51
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Total 2663.50 19038.47 7.15
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Number of Children (Unduplicated) With at Least One Service 59
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Center 53
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 47 50.25 1859.25 0.00
P 57 85.39 4554.32 4605.31
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 127 1047.25 3865.25 3865.25
247 1480.61 8759.65 0.00
Other 0 0.00 0.00 0.00
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Total 478 2663.50 19038.47 8470.56