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: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 24 87.25 3182.00 36.47
Subtotal (Total Children Is Unduplicated) 44 145.00 5318.75 36.68
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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 5 5.00 375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 8 12.00 848.50 70.71
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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 1055.00 6566.25 6.22
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Number of Children (Unduplicated) With at Least One Service 44
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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 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
194 137.25 5070.00 0.00
Other 0 0.00 0.00 0.00
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Total 233 1055.00 6566.25 1172.50