CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 45 29.00 1073.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 15.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 47 150.50 5568.50 37.00
Subtotal (Total Children Is Unduplicated) 82 194.50 6641.50 34.15
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 7.50 375.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 11 9.00 487.50 54.17
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 11 11.00 88.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 160.00 80.00 0.50
Subtotal (Total Children Is Unduplicated) 13 176.50 443.00 2.51
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Total 380.00 7572.00 19.93
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Number of Children (Unduplicated) With at Least One Service 83
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Center 04
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 3 161.50 155.00 155.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 4.00 200.00 200.00
T 0 0.00 0.00 0.00
403 214.50 7217.00 0.00
Other 0 0.00 0.00 0.00
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Total 407 380.00 7572.00 355.00