CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 44 28.00 1036.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 14 14.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 48 153.00 5661.00 37.00
Subtotal (Total Children Is Unduplicated) 78 195.00 6697.00 34.34
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 14 12.50 700.00 56.00
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 9 9.00 65.50 7.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 395.00 197.50 0.50
Subtotal (Total Children Is Unduplicated) 11 414.00 763.00 1.84
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Total 621.50 8160.00 13.13
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Number of Children (Unduplicated) With at Least One Service 78
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Center 04
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 8 405.00 697.50 697.50
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
382 216.50 7462.50 0.00
Other 0 0.00 0.00 0.00
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Total 390 621.50 8160.00 697.50