CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 26 10.00 370.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 79 84.25 3117.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 141 572.50 21182.50 37.00
Subtotal (Total Children Is Unduplicated) 142 666.75 24669.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.50 638.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 46.50 3487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 19.50 1462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 57.00 3163.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.00 1125.00 75.00
Subtotal (Total Children Is Unduplicated) 74 165.50 11076.75 66.93
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 858.00 485.50 0.57
Subtotal (Total Children Is Unduplicated) 18 858.00 485.50 0.57
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Total 1690.25 36232.00 21.44
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Number of Children (Unduplicated) With at Least One Service 143
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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 82 94.75 3505.75 0.00
P 42 426.00 2970.85 2970.85
D 33 39.25 1851.25 0.00
S 49 57.25 2118.25 0.00
H 4 5.00 355.50 0.00
T 41 473.00 3196.65 3196.65
464 425.50 14796.25 0.00
Other 154 169.50 7437.50 0.00
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Total 869 1690.25 36232.00 6167.50