CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 72 34.75 1267.25 36.47
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 119 225.00 8325.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 71 350.50 12968.50 37.00
Subtotal (Total Children Is Unduplicated) 133 619.25 22560.75 36.43
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 63.50 4732.50 74.53
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 46.50 3382.50 72.74
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 60.00 3330.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 74 192.00 12932.00 67.35
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.75 30.00 40.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
INTR-INTR-INTERPRETER 1 5.00 250.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 53 3792.00 1896.00 0.50
Subtotal (Total Children Is Unduplicated) 54 3798.25 2188.50 0.58
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Total 4609.50 37681.25 8.17
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Number of Children (Unduplicated) With at Least One Service 137
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Center 02
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 35 564.00 2377.00 2377.00
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 153 3227.75 10190.25 10190.25
715 817.75 25114.00 0.00
Other 0 0.00 0.00 0.00
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Total 903 4609.50 37681.25 12567.25