CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 4 25.00 925.00 37.00
Subtotal (Total Children Is Unduplicated) 6 32.00 1184.00 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 1 9.00 450.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 8.50 560.01 65.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 6.00 407.28 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 1097.00 533.50 0.49
Subtotal (Total Children Is Unduplicated) 5 1122.25 2038.29 1.82
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Total 1156.25 3319.29 2.87
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Number of Children (Unduplicated) With at Least One Service 7
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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 0 0.00 0.00 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
43 27.75 1026.75 0.00
Other 0 0.00 0.00 0.00
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Total 74 1156.25 3319.29 2135.29