CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 225 87.25 3228.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 256 274.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 315 288.25 10665.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 366 1199.25 44335.25 36.97
Subtotal (Total Children Is Unduplicated) 575 1848.75 58228.75 31.50
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
Subtotal (Total Children Is Unduplicated) 1 3.00 222.78 74.26
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Total 1851.75 58451.53 31.57
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Number of Children (Unduplicated) With at Least One Service 575
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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 0 0.00 0.00 0.00
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
3223 1851.75 58451.53 0.00
Other 0 0.00 0.00 0.00
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Total 3223 1851.75 58451.53 0.00