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: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 67 40.75 1507.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 108 106.75 3949.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 194 722.75 26741.75 37.00
Subtotal (Total Children Is Unduplicated) 195 870.25 32199.25 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.75 37.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.00 562.50 70.31
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 69.00 5175.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 100.00 5550.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 39.50 2962.50 75.00
Subtotal (Total Children Is Unduplicated) 106 234.25 15474.75 66.06
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.25 62.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.50 175.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 238.01 119.01
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 27 1106.00 553.00 0.50
Subtotal (Total Children Is Unduplicated) 28 1112.75 1028.51 0.92
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Total 2217.25 48702.51 21.97
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Number of Children (Unduplicated) With at Least One Service 195
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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 73 705.75 5035.06 5035.06
D 0 0.00 0.00 0.00
S 92 84.75 3135.75 0.00
H 15 17.50 1234.50 0.00
T 79 433.50 5732.75 5732.75
813 630.00 23304.45 0.00
Other 309 345.75 10260.00 0.00
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Total 1381 2217.25 48702.51 10767.81