CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 529 224.75 8315.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 483 510.50 18879.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 962 2327.25 86108.25 37.00
Subtotal (Total Children Is Unduplicated) 1361 3062.50 113303.25 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 2 2.50 125.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 33.00 2475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 23.00 1725.00 75.00
Subtotal (Total Children Is Unduplicated) 42 85.00 5875.25 69.12
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 15.00 750.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 10.00 5.00 0.50
Subtotal (Total Children Is Unduplicated) 10 26.00 805.00 30.96
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Total 3173.50 119983.50 37.81
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Number of Children (Unduplicated) With at Least One Service 1366
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Center 01
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 18 23.50 1555.25 0.00
S 74 59.75 2210.75 0.00
H 15 19.50 1219.00 0.00
T 1 0.75 27.75 0.00
5099 3043.25 113559.00 0.00
Other 26 26.50 1402.50 0.00
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Total 5234 3173.50 119983.50 0.00