CMS/EIP Fiscal Report Center: 52
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 43 17.25 638.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 67 50.00 1840.75 36.82
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 142.25 5254.00 36.93
Subtotal (Total Children Is Unduplicated) 90 210.50 7733.00 36.74
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 11 11.50 550.00 47.83
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.00 610.50 55.50
Subtotal (Total Children Is Unduplicated) 19 24.00 1273.00 53.04
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 49 2304.00 1152.00 0.50
Subtotal (Total Children Is Unduplicated) 49 2304.00 1152.00 0.50
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Total 2538.50 10158.00 4.00
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Number of Children (Unduplicated) With at Least One Service 96
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Center 52
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 4 68.00 133.00 133.00
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
423 2470.50 10025.00 0.00
Other 0 0.00 0.00 0.00
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Total 427 2538.50 10158.00 133.00