CMS/EIP Fiscal Report Center: 54
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 36 15.75 582.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 102 129.00 4773.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 154 593.00 21497.00 36.25
Subtotal (Total Children Is Unduplicated) 154 746.75 26852.75 35.96
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.25 12.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.00 487.50 121.88
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 9.00 675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 36.50 2737.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 42.00 2331.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 43.50 3262.50 75.00
Subtotal (Total Children Is Unduplicated) 82 145.75 10293.50 70.62
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 61 2899.00 2464.15 0.85
Subtotal (Total Children Is Unduplicated) 61 2899.00 2464.15 0.85
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Total 3791.50 39610.40 10.45
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Number of Children (Unduplicated) With at Least One Service 155
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Center 54
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 268 197.75 7385.50 0.00
P 222 2134.25 8977.85 8885.35
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 0 0.00 0.00 0.00
671 1459.50 23247.05 0.00
Other 0 0.00 0.00 0.00
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Total 1161 3791.50 39610.40 8885.35