CMS/EIP Fiscal Report Center: 54
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
CASE-CASE-NON-TCM CASE MANAGEMENT 3 1.00 37.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 17.50 647.50 37.00
Subtotal (Total Children Is Unduplicated) 6 21.50 721.50 33.56
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 2 2.00 111.00 55.50
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 11.00 550.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.50 169.70 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 636.00 487.80 0.77
Subtotal (Total Children Is Unduplicated) 4 649.75 1220.00 1.88
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Total 673.25 2052.50 3.05
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Number of Children (Unduplicated) With at Least One Service 6
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Center 54
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 19 13.50 616.50 0.00
P 26 365.50 762.15 762.15
D 3 0.75 27.75 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
15 293.50 646.10 0.00
Other 0 0.00 0.00 0.00
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Total 63 673.25 2052.50 762.15