CMS/EIP Fiscal Report Center: 57
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 7 7.50 277.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 33 34.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 9.50 351.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 90.50 3348.50 37.00
Subtotal (Total Children Is Unduplicated) 40 141.50 3977.50 28.11
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 3.50 175.00 50.00
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 30 35.00 2625.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 35 88.00 5683.75 64.59
----------------------------------------------------------------------------------------------------------------
Total 229.50 9661.25 42.10
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 40
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 3.75 138.75 0.00
U 0 0.00 0.00 0.00
B 35 57.00 2579.50 0.00
P 0 0.00 0.00 0.00
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
137 168.75 6943.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 177 229.50 9661.25 0.00