CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 54 20.50 758.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.25 83.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 134 253.75 9388.75 37.00
Subtotal (Total Children Is Unduplicated) 164 282.50 10230.50 36.21
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 32.00 2400.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 36.00 1350.00 37.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 62.00 3441.00 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 96 96.00 4800.00 50.00
Subtotal (Total Children Is Unduplicated) 126 235.00 12558.75 53.44
----------------------------------------------------------------------------------------------------------------
Total 517.50 22789.25 44.04
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 185
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
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 326 269.50 12112.75 12112.75
249 248.00 10676.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 575 517.50 22789.25 12112.75