CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 209 100.00 3700.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 293 349.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 345 314.00 11618.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 349 1283.00 47471.00 37.00
Subtotal (Total Children Is Unduplicated) 582 2046.00 62789.00 30.69
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.50 83.25 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 4 6.50 429.00 66.00
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 8.75 437.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 9.00 450.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.00 200.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 16 1270.00 635.00 0.50
Subtotal (Total Children Is Unduplicated) 22 1295.00 1932.39 1.49
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Total 3347.50 65150.39 19.46
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Number of Children (Unduplicated) With at Least One Service 583
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Center 05
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 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 0 0.00 0.00 0.00
3460 3347.50 65150.39 0.00
Other 0 0.00 0.00 0.00
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Total 3460 3347.50 65150.39 0.00