CMS/EIP Fiscal Report Center: 52
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 28 11.00 407.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 38 28.25 1045.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 41 126.75 4634.25 36.56
Subtotal (Total Children Is Unduplicated) 64 167.00 6086.50 36.45
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.50 75.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 10.00 500.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.50 123.50 49.40
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 12 17.00 844.00 49.65
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 0.75 50.91 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 34 1043.00 521.50 0.50
Subtotal (Total Children Is Unduplicated) 34 1043.75 572.41 0.55
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Total 1227.75 7502.91 6.11
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Number of Children (Unduplicated) With at Least One Service 70
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Center 52
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 0 0.00 0.00 0.00
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 11 77.25 432.41 432.41
297 1150.50 7070.50 0.00
Other 0 0.00 0.00 0.00
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Total 308 1227.75 7502.91 432.41