CMS/EIP Fiscal Report Center: 54
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 29 10.50 388.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 103 114.00 4218.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 86 300.75 11016.75 36.63
Subtotal (Total Children Is Unduplicated) 138 429.25 15623.25 36.40
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.00 750.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 24.34 1825.00 74.98
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 24.50 1359.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 29.34 2200.00 74.98
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 0.70 33.50 47.86
Subtotal (Total Children Is Unduplicated) 63 96.88 6768.25 69.86
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 81 3832.00 3256.85 0.85
Subtotal (Total Children Is Unduplicated) 81 3832.00 3256.85 0.85
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Total 4358.13 25648.35 5.89
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Number of Children (Unduplicated) With at Least One Service 143
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Center 54
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 150 2777.38 7534.30 7534.30
D 3 3.50 129.50 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
594 1577.25 17984.55 0.00
Other 0 0.00 0.00 0.00
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Total 747 4358.13 25648.35 7534.30