CMS/EIP Fiscal Report Center: 55
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 8 3.75 138.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 20 25.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 2.75 101.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 162.25 5910.75 36.43
Subtotal (Total Children Is Unduplicated) 37 193.75 6151.25 31.75
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.50 1687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 23.00 1725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.50 971.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
Subtotal (Total Children Is Unduplicated) 25 84.00 5929.50 70.59
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Total 277.75 12080.75 43.50
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Number of Children (Unduplicated) With at Least One Service 37
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Center 55
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 25 22.00 814.00 0.00
P 72 83.47 3799.73 3799.73
D 8 10.00 427.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 3 5.50 334.50 334.50
138 156.78 6705.52 0.00
Other 0 0.00 0.00 0.00
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Total 246 277.75 12080.75 4134.23