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: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 36 16.00 592.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 97 130.00 4810.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 165 610.50 22570.00 36.97
Subtotal (Total Children Is Unduplicated) 165 756.50 27972.00 36.98
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 43.00 3225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 60.50 3357.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 68.50 5137.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 89 213.50 14653.00 68.63
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 85 6069.00 4274.95 0.70
Subtotal (Total Children Is Unduplicated) 85 6076.50 4676.77 0.77
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Total 7046.50 47301.77 6.71
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Number of Children (Unduplicated) With at Least One Service 165
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Center 54
Flag Claims Units Chgs Paid
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R 1 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 238 203.75 9283.25 0.00
P 362 3869.41 14134.87 14134.87
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
629 2972.34 23833.65 0.00
Other 0 0.00 0.00 0.00
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Total 1230 7046.50 47301.77 14134.87