CMS/EIP Fiscal Report Center: 55
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 20 6.75 249.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 20 21.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 29 19.00 703.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 52 252.75 9296.25 36.78
Subtotal (Total Children Is Unduplicated) 52 299.50 10249.00 34.22
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.50 225.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 58.50 4387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 32.00 2400.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.00 1110.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.50 787.50 75.00
Subtotal (Total Children Is Unduplicated) 38 140.00 9997.50 71.41
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Total 439.50 20246.50 46.07
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Number of Children (Unduplicated) With at Least One Service 52
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Center 55
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 10 12.50 519.50 0.00
P 127 157.25 7164.75 7164.75
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
248 269.75 12562.25 0.00
Other 0 0.00 0.00 0.00
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Total 385 439.50 20246.50 7164.75