CMS/EIP Fiscal Report Center: 57
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 6 2.75 101.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 35 45.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 17.25 638.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 75.25 2784.25 37.00
Subtotal (Total Children Is Unduplicated) 46 140.25 3524.25 25.13
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Screening, Eval, and Assessment,Class #02
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 2 2.00 60.00 30.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 13.00 721.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 18 32.00 1956.50 61.14
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Total 172.25 5480.75 31.82
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Number of Children (Unduplicated) With at Least One Service 46
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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 0 0.00 0.00 0.00
166 172.25 5480.75 0.00
Other 0 0.00 0.00 0.00
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Total 166 172.25 5480.75 0.00