CMS/EIP Fiscal Report Center: 55
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 17 8.00 296.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 25 27.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 8.25 305.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 102.50 3746.25 36.55
Subtotal (Total Children Is Unduplicated) 52 145.75 4347.50 29.83
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.50 225.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.97 1047.56 74.99
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 18 40.97 2726.06 66.54
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Total 186.72 7073.56 37.88
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Number of Children (Unduplicated) With at Least One Service 55
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Center 55
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 21 34.97 2388.56 2388.56
D 5 3.75 195.75 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
174 148.00 4489.25 0.00
Other 0 0.00 0.00 0.00
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Total 200 186.72 7073.56 2388.56