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: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 24 19.00 703.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 38.75 1433.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 53 214.00 7871.75 36.78
Subtotal (Total Children Is Unduplicated) 53 271.75 10008.50 36.83
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 8.00 600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 11.00 800.00 72.73
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 16 26.00 1801.00 69.27
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 898.00 399.00 0.44
Subtotal (Total Children Is Unduplicated) 10 898.00 399.00 0.44
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Total 1195.75 12208.50 10.21
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Number of Children (Unduplicated) With at Least One Service 53
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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 174 130.75 4989.75 0.00
P 30 909.00 1172.50 1172.50
D 9 8.75 323.75 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
204 147.25 5722.50 0.00
Other 0 0.00 0.00 0.00
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Total 417 1195.75 12208.50 1172.50