CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 25 8.75 323.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 87 195.75 7242.75 37.00
Subtotal (Total Children Is Unduplicated) 109 207.75 7686.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
Subtotal (Total Children Is Unduplicated) 4 4.50 293.00 65.11
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.00 650.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 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) 11 2227.00 2296.04 1.03
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Total 2439.25 10275.79 4.21
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Number of Children (Unduplicated) With at Least One Service 116
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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 338 182.75 6761.75 0.00
H 0 0.00 0.00 0.00
T 31 762.50 1316.66 1316.66
76 205.00 1089.50 0.00
Other 0 0.00 0.00 0.00
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Total 474 2439.25 10275.79 2424.54