CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 30.00 1110.00 37.00
Subtotal (Total Children Is Unduplicated) 33 35.00 1110.00 31.71
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 64.50 4837.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 74.00 4107.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.50 487.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 61 156.50 10199.75 65.17
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 26 25.00 1250.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 9.00 225.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 23.00 1150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 8 6.50 162.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 384.00 3456.00 9.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 13.00 882.44 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 12.00 814.56 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 35 2721.00 1360.50 0.50
Subtotal (Total Children Is Unduplicated) 77 3206.50 10022.52 3.13
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Total 3398.00 21332.27 6.28
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Number of Children (Unduplicated) With at Least One Service 161
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Center 57
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 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 2 5.00 250.00 250.00
255 3082.50 17520.99 0.00
Other 86 310.50 3561.28 3561.28
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Total 343 3398.00 21332.27 3811.28