CMS/EIP Fiscal Report Center: 52
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 27 11.25 416.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 32.75 1211.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 246.50 9113.25 36.97
Subtotal (Total Children Is Unduplicated) 59 291.50 10741.25 36.85
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.50 200.00 44.44
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 52.04 3573.50 68.67
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 286.00 47.67
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 46.50 2575.25 55.38
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 45 131.54 8183.25 62.21
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 28 1238.00 619.00 0.50
Subtotal (Total Children Is Unduplicated) 28 1238.00 619.00 0.50
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Total 1661.04 19543.50 11.77
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Number of Children (Unduplicated) With at Least One Service 59
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Center 52
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 67 63.75 2838.50 0.00
P 106 129.50 3671.25 3671.25
D 0 0.00 0.00 0.00
S 15 10.00 370.00 0.00
H 7 10.50 748.50 0.00
T 0 0.00 0.00 0.00
327 1447.29 11915.25 0.00
Other 0 0.00 0.00 0.00
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Total 522 1661.04 19543.50 3671.25