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: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 65 40.25 1489.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 105 103.00 3811.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 116 412.75 15271.75 37.00
Subtotal (Total Children Is Unduplicated) 167 556.00 20572.00 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 3 3.00 225.00 75.00
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 36 44.50 3337.50 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 42 58.50 3246.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 15.50 1162.50 75.00
Subtotal (Total Children Is Unduplicated) 63 139.25 9196.50 66.04
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.25 62.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 58.06 58.06
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 27 1106.00 553.00 0.50
Subtotal (Total Children Is Unduplicated) 28 1108.25 673.56 0.61
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Total 1803.50 30442.06 16.88
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Number of Children (Unduplicated) With at Least One Service 172
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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 15 15.00 555.00 0.00
H 3 3.00 225.00 0.00
T 52 398.00 3372.50 3372.50
761 580.75 20851.00 0.00
Other 8 101.00 403.50 0.00
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Total 912 1803.50 30442.06 8407.56