CMS/EIP Fiscal Report Center: 55
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 20 6.75 249.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 20 21.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 29 19.00 703.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 101.25 3709.25 36.63
Subtotal (Total Children Is Unduplicated) 46 148.00 4662.00 31.50
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.00 150.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.50 787.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
Subtotal (Total Children Is Unduplicated) 13 37.50 2620.50 69.88
----------------------------------------------------------------------------------------------------------------
Total 185.50 7282.50 39.26
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 48
----------------------------------------------------------------------------------------------------------------
Center 55
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 19 34.50 2470.50 2470.50
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
180 151.00 4812.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 199 185.50 7282.50 2470.50