CMS/EIP Fiscal Report Center: 55
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 31 12.50 453.25 36.26
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 27 30.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 15.25 564.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 145.75 5392.75 37.00
Subtotal (Total Children Is Unduplicated) 56 203.50 6410.25 31.50
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 22.90 1717.62 75.01
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.50 971.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 19 54.40 3738.87 68.73
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 2.00 70.00 35.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 56.00 24.92 0.45
Subtotal (Total Children Is Unduplicated) 1 58.00 94.92 1.64
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Total 315.90 10244.04 32.43
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Number of Children (Unduplicated) With at Least One Service 57
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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 7 12.50 820.50 820.50
D 3 5.25 194.25 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 24 96.90 2788.29 2788.29
241 201.25 6441.00 0.00
Other 0 0.00 0.00 0.00
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Total 275 315.90 10244.04 3608.79