CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Eligibility Filter:DEI Only
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 3 3.75 138.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.25 120.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 34.00 1258.00 37.00
Subtotal (Total Children Is Unduplicated) 8 41.00 1517.00 37.00
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Screening, Eval, and Assessment,Class #02
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 97.00 48.50
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 1.75 87.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.00 500.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 8.50 560.01 65.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 17.00 1153.96 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 1097.00 533.50 0.49
Subtotal (Total Children Is Unduplicated) 5 1134.25 2834.97 2.50
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Total 1177.25 4448.97 3.78
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Number of Children (Unduplicated) With at Least One Service 8
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Center 51
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 14 9.00 333.00 0.00
P 24 1124.25 2135.29 2135.29
D 7 4.25 157.25 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
48 39.75 1823.43 0.00
Other 0 0.00 0.00 0.00
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Total 93 1177.25 4448.97 2135.29