CMS/EIP Fiscal Report Center: 52
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 25 10.00 370.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 41.50 1535.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 60 216.00 7973.50 36.91
Subtotal (Total Children Is Unduplicated) 60 267.50 9879.00 36.93
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 50.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 17 22.00 1092.50 49.66
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 34.00 2228.50 65.54
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.00 794.00 66.17
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 32.50 1803.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 45 108.50 6392.25 58.91
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 35 1583.00 791.50 0.50
Subtotal (Total Children Is Unduplicated) 35 1583.00 791.50 0.50
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Total 1959.00 17062.75 8.71
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Number of Children (Unduplicated) With at Least One Service 61
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Center 52
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 91 66.25 2517.50 0.00
P 69 55.25 2550.25 2550.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 7 10.50 699.75 0.00
T 0 0.00 0.00 0.00
355 1827.00 11295.25 0.00
Other 0 0.00 0.00 0.00
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Total 522 1959.00 17062.75 2550.25