CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 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 11 4.50 166.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.00 111.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 107 162.75 6021.75 37.00
Subtotal (Total Children Is Unduplicated) 116 171.25 6299.25 36.78
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.50 1162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.00 777.00 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 90 90.00 4500.00 50.00
Subtotal (Total Children Is Unduplicated) 95 121.00 6552.00 54.15
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 120.00 60.00 0.50
Subtotal (Total Children Is Unduplicated) 1 126.00 310.00 2.46
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Total 418.25 13161.25 31.47
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Number of Children (Unduplicated) With at Least One Service 133
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Center 03
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 3 102.00 100.00 100.00
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 307 285.25 12453.25 12453.25
13 31.00 608.00 0.00
Other 0 0.00 0.00 0.00
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Total 323 418.25 13161.25 12553.25