CMS/EIP Fiscal Report Center: 57
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 6 3.25 120.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 35 39.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 26 24.75 915.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 119.00 4403.00 37.00
Subtotal (Total Children Is Unduplicated) 45 186.00 5439.00 29.24
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Screening, Eval, and Assessment,Class #02
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 1 1.00 30.00 30.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 14.00 1050.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 23 44.00 2777.50 63.13
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.50 75.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.50 75.00 50.00
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Total 231.50 8291.50 35.82
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Number of Children (Unduplicated) With at Least One Service 45
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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 2 2.50 123.50 123.50
204 229.00 8168.00 0.00
Other 0 0.00 0.00 0.00
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Total 206 231.50 8291.50 123.50