CMS/EIP Fiscal Report Center: 09
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 44 32.75 1211.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 65 55.25 2044.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 151 326.50 12080.50 37.00
Subtotal (Total Children Is Unduplicated) 154 414.50 15336.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 14.00 1050.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.00 600.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 141.50 10612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.00 2325.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 61 73.50 5512.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 101.50 5633.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 30.50 2287.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 151 416.00 29028.75 69.78
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9 541.00 270.50 0.50
Subtotal (Total Children Is Unduplicated) 9 541.00 270.50 0.50
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Total 1371.50 44635.75 32.55
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Number of Children (Unduplicated) With at Least One Service 197
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Center 09
Flag Claims Units Chgs Paid
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R 10 15.25 697.25 0.00
U 0 0.00 0.00 0.00
B 205 250.00 13791.50 0.00
P 233 699.50 13044.25 13044.25
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 148 226.00 5890.00 5890.00
150 180.75 11212.75 0.00
Other 0 0.00 0.00 0.00
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Total 746 1371.50 44635.75 18934.25