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: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 64 43.75 1618.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 106 106.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 258.00 9546.00 37.00
Subtotal (Total Children Is Unduplicated) 121 407.75 11164.75 27.38
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 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 11 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 22.50 1248.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 27.50 2062.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 63 75.00 5198.75 69.32
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 80 81.00 648.00 8.00
Subtotal (Total Children Is Unduplicated) 80 81.00 648.00 8.00
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Total 563.75 17011.50 30.18
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Number of Children (Unduplicated) With at Least One Service 121
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Center 04
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 3 2.00 74.00 74.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
515 561.75 16937.50 0.00
Other 0 0.00 0.00 0.00
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Total 518 563.75 17011.50 74.00