CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
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 5 3.75 138.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 171 313.25 11590.25 37.00
Subtotal (Total Children Is Unduplicated) 171 318.00 11766.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 22.50 1687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
Subtotal (Total Children Is Unduplicated) 24 41.50 3015.00 72.65
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Total 359.50 14781.00 41.12
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Number of Children (Unduplicated) With at Least One Service 192
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Center 09
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
439 359.50 14781.00 0.00
Other 0 0.00 0.00 0.00
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Total 439 359.50 14781.00 0.00