CMS/EIP Fiscal Report Center: 06
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 10 8.25 305.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 17 17.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 24.25 897.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 37.25 1378.25 37.00
Subtotal (Total Children Is Unduplicated) 55 86.75 2580.75 29.75
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 1 4.00 300.00 75.00
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.00 550.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 582.00 291.00 0.50
Subtotal (Total Children Is Unduplicated) 3 593.00 841.00 1.42
----------------------------------------------------------------------------------------------------------------
Total 683.75 3721.75 5.44
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 55
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
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 45 199.00 794.50 794.50
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
131 484.75 2927.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 176 683.75 3721.75 794.50