CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 36 15.75 582.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 101 128.50 4754.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 79 298.75 10859.50 36.35
Subtotal (Total Children Is Unduplicated) 134 452.00 16196.75 35.83
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.25 12.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 29.00 2175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 54 81.75 5715.50 69.91
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 61 2899.00 2464.15 0.85
Subtotal (Total Children Is Unduplicated) 61 2899.00 2464.15 0.85
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Total 3432.75 24376.40 7.10
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Number of Children (Unduplicated) With at Least One Service 137
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Center 54
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 120 2048.50 5897.60 5897.60
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
603 1384.25 18478.80 0.00
Other 0 0.00 0.00 0.00
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Total 723 3432.75 24376.40 5897.60