CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 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 49 48.75 1803.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 58 59.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 28 29.50 1091.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 46.50 1720.50 37.00
Subtotal (Total Children Is Unduplicated) 66 183.75 4615.75 25.12
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 9 9.00 450.00 50.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 10 11.00 550.15 50.01
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.75 37.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 29.50 1475.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 705.00 352.50 0.50
Subtotal (Total Children Is Unduplicated) 1 736.75 1940.00 2.63
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Total 931.50 7105.90 7.63
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Number of Children (Unduplicated) With at Least One Service 66
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Center 05
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 26 736.75 1940.00 1940.00
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
368 194.75 5165.90 0.00
Other 0 0.00 0.00 0.00
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Total 394 931.50 7105.90 1940.00