CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 61 38.25 1415.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 21 21.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 48 155.50 5753.50 37.00
Subtotal (Total Children Is Unduplicated) 84 215.50 7196.50 33.39
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 14 13.75 687.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 0.75 37.50 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 3.50 262.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 20 25.00 1814.00 72.56
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.00 650.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 14 14.00 92.50 6.61
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 555.00 277.50 0.50
Subtotal (Total Children Is Unduplicated) 16 582.00 1020.00 1.75
----------------------------------------------------------------------------------------------------------------
Total 822.50 10030.50 12.20
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 84
----------------------------------------------------------------------------------------------------------------
Center 04
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 9 568.00 927.50 927.50
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
439 254.50 9103.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 448 822.50 10030.50 927.50