CMS/EIP Fiscal Report Center: 52
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 25 10.00 370.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 41.50 1535.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 117.00 4329.00 37.00
Subtotal (Total Children Is Unduplicated) 52 168.50 6234.50 37.00
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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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 17 18.00 898.50 49.92
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 97.00 48.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 20 26.00 1381.50 53.13
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 34 1440.00 720.00 0.50
Subtotal (Total Children Is Unduplicated) 34 1440.00 720.00 0.50
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Total 1634.50 8336.00 5.10
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Number of Children (Unduplicated) With at Least One Service 58
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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 0 0.00 0.00 0.00
P 1 0.25 9.25 9.25
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
312 1634.25 8326.75 0.00
Other 0 0.00 0.00 0.00
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Total 313 1634.50 8336.00 9.25