CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 9 6.50 240.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 10.50 388.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 43.00 1591.00 37.00
Subtotal (Total Children Is Unduplicated) 13 60.00 2220.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 3.00 150.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 5 8.50 509.50 59.94
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 2.25 112.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 18.00 900.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 15.00 1001.23 66.75
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 27.00 1832.76 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 5324.00 3383.50 0.64
Subtotal (Total Children Is Unduplicated) 8 5386.25 7229.99 1.34
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Total 5454.75 9959.49 1.83
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Number of Children (Unduplicated) With at Least One Service 13
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Center 51
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 89 5393.25 7626.99 7626.99
D 10 6.25 231.25 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
98 55.25 2101.25 0.00
Other 0 0.00 0.00 0.00
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Total 197 5454.75 9959.49 7626.99