CMS/EIP Fiscal Report Center: 04
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 52 18.75 693.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 79 79.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 7.00 259.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 120 547.00 20239.00 37.00
Subtotal (Total Children Is Unduplicated) 120 651.75 21191.75 32.52
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 17.50 1312.50 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 24 20.00 1500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 52.50 2913.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 49.00 3675.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.00 4995.00 185.00
Subtotal (Total Children Is Unduplicated) 82 169.00 14601.75 86.40
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 66 69.00 475.50 6.89
Subtotal (Total Children Is Unduplicated) 66 69.00 475.50 6.89
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Total 889.75 36269.00 40.76
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Number of Children (Unduplicated) With at Least One Service 120
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Center 04
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 213 307.50 11508.00 0.00
P 25 19.50 1714.50 1568.10
D 5 5.00 277.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
550 557.75 22769.00 0.00
Other 0 0.00 0.00 0.00
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Total 793 889.75 36269.00 1568.10