CMS/EIP Fiscal Report Center: 05
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 9 5.75 212.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 16.50 610.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 35 166.50 6160.50 37.00
Subtotal (Total Children Is Unduplicated) 35 188.75 6983.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 12.00 900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 16.00 888.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 18 41.50 2742.00 66.07
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 420.00 210.00 0.50
Subtotal (Total Children Is Unduplicated) 13 421.00 277.88 0.66
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Total 651.25 10003.63 15.36
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Number of Children (Unduplicated) With at Least One Service 35
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Center 05
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 93 68.00 2516.00 0.00
P 29 320.50 1365.75 1365.75
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 0 0.00 0.00 0.00
206 262.75 6121.88 0.00
Other 0 0.00 0.00 0.00
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Total 328 651.25 10003.63 1365.75