CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 25 8.75 323.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 187 409.75 15160.75 37.00
Subtotal (Total Children Is Unduplicated) 188 421.75 15604.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.00 222.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 16.00 1200.00 75.00
Subtotal (Total Children Is Unduplicated) 21 28.50 2005.25 70.36
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 21.00 1050.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 6.00 407.28 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.00 475.16 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 2206.00 1103.00 0.50
Subtotal (Total Children Is Unduplicated) 12 2240.00 3035.44 1.36
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Total 2690.25 20645.44 7.67
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Number of Children (Unduplicated) With at Least One Service 189
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Center 01
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 29 1289.00 1107.88 1107.88
D 0 0.00 0.00 0.00
S 378 209.75 7760.75 0.00
H 0 0.00 0.00 0.00
T 50 781.50 2623.41 2623.41
90 218.00 1789.90 0.00
Other 347 192.00 7363.50 0.00
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Total 894 2690.25 20645.44 3731.29