CMS/EIP Fiscal Report Center: 05
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 35 15.75 582.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 24 24.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 7.75 286.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 17.50 647.50 37.00
Subtotal (Total Children Is Unduplicated) 46 65.00 1517.00 23.34
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 6 7.00 350.15 50.02
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 120.00 60.00 0.50
Subtotal (Total Children Is Unduplicated) 1 128.75 497.50 3.86
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Total 200.75 2364.65 11.78
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Number of Children (Unduplicated) With at Least One Service 49
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Center 05
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 6 128.75 497.50 497.50
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
127 72.00 1867.15 0.00
Other 0 0.00 0.00 0.00
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Total 133 200.75 2364.65 497.50