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: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 45 21.25 786.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 84 84.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 7.50 277.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 130.50 4828.50 37.00
Subtotal (Total Children Is Unduplicated) 90 243.25 5892.25 24.22
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 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 9 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 16.00 888.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 24.50 1837.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
Subtotal (Total Children Is Unduplicated) 45 57.50 4201.00 73.06
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 59 60.00 480.00 8.00
Subtotal (Total Children Is Unduplicated) 59 60.00 480.00 8.00
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Total 360.75 10573.25 29.31
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Number of Children (Unduplicated) With at Least One Service 90
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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 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 0 0.00 0.00 0.00
350 360.75 10573.25 0.00
Other 0 0.00 0.00 0.00
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Total 350 360.75 10573.25 0.00