CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 17 9.25 342.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 44.00 1628.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 106.75 3894.25 36.48
Subtotal (Total Children Is Unduplicated) 32 160.00 5864.50 36.65
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.00 1125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 13.00 721.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.50 825.00 71.74
Subtotal (Total Children Is Unduplicated) 15 50.50 3496.50 69.24
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 20 1859.00 929.50 0.50
Subtotal (Total Children Is Unduplicated) 20 1859.00 929.50 0.50
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Total 2069.50 10290.50 4.97
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Number of Children (Unduplicated) With at Least One Service 33
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Center 02
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 67 66.50 2405.00 0.00
P 0 0.00 0.00 0.00
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 27 1143.50 1397.25 1397.25
124 859.50 6488.25 0.00
Other 0 0.00 0.00 0.00
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Total 218 2069.50 10290.50 1397.25