CMS/EIP Fiscal Report Center: 02
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 8 2.75 101.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 41.00 1517.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 127.25 4708.25 37.00
Subtotal (Total Children Is Unduplicated) 31 172.00 6327.00 36.78
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
Subtotal (Total Children Is Unduplicated) 12 28.00 1875.75 66.99
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.75 30.00 40.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 801.00 400.50 0.50
Subtotal (Total Children Is Unduplicated) 12 801.75 430.50 0.54
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Total 1001.75 8633.25 8.62
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Number of Children (Unduplicated) With at Least One Service 31
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Center 02
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 70 70.25 2599.25 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 21 446.75 1337.75 1337.75
109 484.75 4696.25 0.00
Other 0 0.00 0.00 0.00
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Total 200 1001.75 8633.25 1337.75