CMS/EIP Fiscal Report Center: 57
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 6 4.00 148.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 36 38.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 15.50 573.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 20 78.00 2886.00 37.00
Subtotal (Total Children Is Unduplicated) 46 135.50 3607.50 26.62
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 22.00 1165.50 52.98
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 16 40.00 2490.50 62.26
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Total 175.50 6098.00 34.75
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Number of Children (Unduplicated) With at Least One Service 46
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Center 57
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 6 5.50 288.25 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
148 170.00 5809.75 0.00
Other 0 0.00 0.00 0.00
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Total 154 175.50 6098.00 0.00