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: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 75 273.75 10128.75 37.00
Subtotal (Total Children Is Unduplicated) 114 368.00 13616.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 33.50 2512.50 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 7 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 36.00 1998.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 46 102.50 6888.00 67.20
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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 1328.50 20989.50 15.80
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Number of Children (Unduplicated) With at Least One Service 118
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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 42 426.00 2970.85 2970.85
D 6 10.50 787.50 0.00
S 13 14.50 536.50 0.00
H 1 1.00 55.50 0.00
T 41 473.00 3196.65 3196.65
444 400.50 13217.50 0.00
Other 2 3.00 225.00 0.00
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Total 549 1328.50 20989.50 6167.50