CMS/EIP Fiscal Report Center: 55
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 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 15 70.50 2553.00 36.21
Subtotal (Total Children Is Unduplicated) 28 102.00 2793.50 27.39
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.12 609.08 75.01
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.85 513.40 74.95
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
Subtotal (Total Children Is Unduplicated) 11 26.47 1877.73 70.94
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Total 128.47 4671.23 36.36
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Number of Children (Unduplicated) With at Least One Service 30
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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 0 0.00 0.00 0.00
P 9 12.97 943.23 943.23
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
100 100.00 2966.50 0.00
Other 0 0.00 0.00 0.00
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Total 120 128.47 4671.23 1277.73