CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
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 4 1.50 55.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.50 166.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 41.75 1544.75 37.00
Subtotal (Total Children Is Unduplicated) 11 47.75 1766.75 37.00
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 1 1.00 48.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.00 500.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 6.50 441.22 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 32.00 2172.16 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 1927.00 913.50 0.47
Subtotal (Total Children Is Unduplicated) 6 1975.50 4026.88 2.04
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Total 2024.25 5842.13 2.89
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Number of Children (Unduplicated) With at Least One Service 11
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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 36 28.00 1036.00 0.00
P 34 1961.50 3130.20 3130.20
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
48 34.75 1675.93 0.00
Other 0 0.00 0.00 0.00
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Total 118 2024.25 5842.13 3130.20