CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Eligibility Filter:DEI Only
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 17 8.50 314.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 8.00 296.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 135 186.50 6900.50 37.00
Subtotal (Total Children Is Unduplicated) 135 203.00 7511.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.50 787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 7.50 416.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 19.50 1462.50 75.00
Subtotal (Total Children Is Unduplicated) 25 46.50 3341.25 71.85
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 23.00 1150.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 5.50 373.34 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 1384.00 775.70 0.56
Subtotal (Total Children Is Unduplicated) 15 1414.50 2399.04 1.70
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Total 1664.00 13251.29 7.96
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Number of Children (Unduplicated) With at Least One Service 138
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Center 01
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 53 32.25 1193.25 0.00
P 26 582.00 666.80 666.80
D 17 14.00 556.00 0.00
S 75 45.75 1692.75 0.00
H 1 1.00 75.00 0.00
T 29 685.50 1116.30 1116.30
119 184.75 2291.19 0.00
Other 159 118.75 5660.00 0.00
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Total 479 1664.00 13251.29 1783.10