CMS/EIP Fiscal Report Center: 04
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 55 24.00 888.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 73 73.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 186.25 6891.25 37.00
Subtotal (Total Children Is Unduplicated) 94 286.50 7899.50 27.57
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 18.00 1350.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
Subtotal (Total Children Is Unduplicated) 32 51.00 3804.00 74.59
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 53 53.00 424.00 8.00
Subtotal (Total Children Is Unduplicated) 53 53.00 424.00 8.00
----------------------------------------------------------------------------------------------------------------
Total 390.50 12127.50 31.06
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 94
----------------------------------------------------------------------------------------------------------------
Center 04
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 7 12.00 444.00 18.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
393 378.50 11683.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 400 390.50 12127.50 18.50