CMS/EIP Fiscal Report Center: 04
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 61 20.75 767.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 104 104.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 127 639.25 23652.25 37.00
Subtotal (Total Children Is Unduplicated) 127 765.00 24457.00 31.97
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 24.50 1801.00 73.51
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 15.00 1125.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 63.00 3442.00 54.63
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 49.50 3712.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.00 5735.00 185.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 104 189.00 16183.25 85.63
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 72 73.00 584.00 8.00
Subtotal (Total Children Is Unduplicated) 72 73.00 584.00 8.00
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Total 1027.00 41224.25 40.14
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Number of Children (Unduplicated) With at Least One Service 127
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Center 04
Flag Claims Units Chgs Paid
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R 16 14.00 744.50 0.00
U 0 0.00 0.00 0.00
B 174 228.50 10171.50 0.00
P 108 173.50 6457.50 6448.68
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 0 0.00 0.00 0.00
601 611.00 23850.75 0.00
Other 0 0.00 0.00 0.00
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Total 899 1027.00 41224.25 6448.68