CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2008 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 33 19.00 703.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 173 193.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 121 99.50 3681.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 118 646.00 23902.00 37.00
Subtotal (Total Children Is Unduplicated) 198 957.50 28286.50 29.54
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Screening, Eval, and Assessment,Class #02
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 3 3.00 90.00 30.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 47.50 3562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 38.50 2834.50 73.62
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 95.50 5294.75 55.44
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 26.50 1962.50 74.06
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 107 226.00 14623.25 64.70
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.50 75.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 600.00 300.00 0.50
Subtotal (Total Children Is Unduplicated) 11 601.50 375.00 0.62
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Total 1785.00 43284.75 24.25
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Number of Children (Unduplicated) With at Least One Service 198
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Center 57
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 9 188.50 624.50 624.50
1030 1596.50 42660.25 180.00
Other 0 0.00 0.00 0.00
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Total 1039 1785.00 43284.75 804.50