CMS/EIP Fiscal Report Center: 05
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 9 5.75 212.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 16.50 610.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 98.50 3644.50 37.00
Subtotal (Total Children Is Unduplicated) 32 120.75 4467.75 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 3 3.00 225.00 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 9 13.50 749.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 13 22.50 1365.75 60.70
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 420.00 210.00 0.50
Subtotal (Total Children Is Unduplicated) 12 420.00 210.00 0.50
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Total 563.25 6043.50 10.73
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Number of Children (Unduplicated) With at Least One Service 33
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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 0 0.00 0.00 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
189 242.75 4677.75 0.00
Other 0 0.00 0.00 0.00
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Total 218 563.25 6043.50 1365.75