CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
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 39 27.00 999.00 37.00
Subtotal (Total Children Is Unduplicated) 55 43.50 1609.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.50 487.50 75.00
Subtotal (Total Children Is Unduplicated) 7 7.50 562.50 75.00
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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 2 10.00 500.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 1384.00 775.70 0.56
Subtotal (Total Children Is Unduplicated) 11 1396.00 1375.70 0.99
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Total 1447.00 3547.70 2.45
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Number of Children (Unduplicated) With at Least One Service 66
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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 0 0.00 0.00 0.00
P 26 582.00 666.80 666.80
D 1 1.00 75.00 0.00
S 23 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 29 685.50 1116.30 1116.30
96 165.50 1318.10 0.00
Other 2 3.00 1.50 0.00
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Total 177 1447.00 3547.70 1783.10