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: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 53 19.25 712.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 101 101.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.75 101.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 64 271.00 10027.00 37.00
Subtotal (Total Children Is Unduplicated) 122 394.00 10841.00 27.52
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 15.50 1162.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 42.50 2358.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 37.50 2812.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 80 121.00 8249.00 68.17
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 84 85.00 641.50 7.55
Subtotal (Total Children Is Unduplicated) 84 85.00 641.50 7.55
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Total 600.00 19731.50 32.89
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Number of Children (Unduplicated) With at Least One Service 122
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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 0 0.00 0.00 0.00
D 5 7.00 259.00 259.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
561 593.00 19472.50 0.00
Other 0 0.00 0.00 0.00
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Total 566 600.00 19731.50 259.00