CMS/EIP Fiscal Report Center: 54
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 1.25 46.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 7.75 286.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 41.50 1526.25 36.78
Subtotal (Total Children Is Unduplicated) 16 56.50 1859.25 32.91
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.50 75.00 50.00
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 2 2.50 138.75 55.50
Subtotal (Total Children Is Unduplicated) 7 8.00 513.75 64.22
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 399.00 314.65 0.79
Subtotal (Total Children Is Unduplicated) 5 399.00 314.65 0.79
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Total 463.50 2687.65 5.80
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Number of Children (Unduplicated) With at Least One Service 16
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Center 54
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 29 15.75 582.75 0.00
P 54 271.75 1290.65 1290.65
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
31 176.00 814.25 0.00
Other 0 0.00 0.00 0.00
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Total 114 463.50 2687.65 1290.65