CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 50 32.25 1193.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 14 14.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 144.00 5328.00 37.00
Subtotal (Total Children Is Unduplicated) 89 190.25 6521.25 34.28
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 11 9.50 475.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 12 12.00 762.75 63.56
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.00 350.00 50.00
TRAN-TRAN-FAMILY TRANSPORTATION 6 6.00 48.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 523.00 261.50 0.50
Subtotal (Total Children Is Unduplicated) 9 536.00 659.50 1.23
----------------------------------------------------------------------------------------------------------------
Total 738.25 7943.50 10.76
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 91
----------------------------------------------------------------------------------------------------------------
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 12 530.00 611.50 611.50
D 10 8.00 296.00 296.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
396 200.25 7036.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 418 738.25 7943.50 907.50