CMS/EIP Fiscal Report Center: 07
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 78 60.00 2220.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 66 107.75 3986.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 74 203.00 7511.00 37.00
Subtotal (Total Children Is Unduplicated) 127 370.75 13717.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.00 675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.00 1598.50 55.12
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 58.00 4350.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 37 111.50 7661.00 68.71
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 1.25 62.50 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 25 1143.00 570.50 0.50
Subtotal (Total Children Is Unduplicated) 28 1144.25 633.00 0.55
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Total 1626.50 22011.75 13.53
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Number of Children (Unduplicated) With at Least One Service 127
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Center 07
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 438 1222.50 16184.00 16184.00
D 6 7.50 505.50 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
152 396.50 5322.25 0.00
Other 0 0.00 0.00 0.00
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Total 596 1626.50 22011.75 16184.00