CMS/EIP Fiscal Report Center: 05
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 12 5.75 212.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 19.50 721.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 144.25 5337.25 37.00
Subtotal (Total Children Is Unduplicated) 27 170.50 6271.50 36.78
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 55.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.97 338.04 56.62
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 14 26.47 1583.04 59.81
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 285.00 142.50 0.50
Subtotal (Total Children Is Unduplicated) 8 285.00 142.50 0.50
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Total 481.97 7997.04 16.59
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Number of Children (Unduplicated) With at Least One Service 27
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Center 05
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 50 30.50 1128.50 0.00
P 22 304.97 1286.79 1286.79
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
226 146.50 5581.75 0.00
Other 0 0.00 0.00 0.00
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Total 298 481.97 7997.04 1286.79