CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.75 64.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 14.75 545.75 37.00
Subtotal (Total Children Is Unduplicated) 6 18.50 610.50 33.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 1 4.00 261.00 65.25
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 10.50 712.74 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 6.00 457.66 76.28
Subtotal (Total Children Is Unduplicated) 3 18.00 1272.22 70.68
----------------------------------------------------------------------------------------------------------------
Total 40.50 2143.72 52.93
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 6
----------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 2.00 74.00 0.00
U 0 0.00 0.00 0.00
B 8 5.00 185.00 0.00
P 4 2.25 129.57 129.57
D 0 0.00 0.00 0.00
S 3 1.00 37.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
24 30.25 1718.15 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 42 40.50 2143.72 129.57