CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 Page: 1
Payclass Filters:GR
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 74 278.50 10304.50 37.00
Subtotal (Total Children Is Unduplicated) 138 424.50 15706.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.00 900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.16 1136.27 74.95
Subtotal (Total Children Is Unduplicated) 29 65.16 4486.52 68.85
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 85 6069.00 4274.95 0.70
Subtotal (Total Children Is Unduplicated) 85 6070.00 4324.95 0.71
----------------------------------------------------------------------------------------------------------------
Total 6559.66 24517.97 3.74
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 144
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
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 110 3662.66 5979.87 5979.87
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
571 2897.00 18538.10 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 681 6559.66 24517.97 5979.87