CMS/EIP Fiscal Report Center: 54
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 29 10.50 388.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 103 114.00 4218.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 164 589.25 21506.25 36.50
Subtotal (Total Children Is Unduplicated) 164 717.75 26112.75 36.38
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.50 337.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 49.00 3675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 38.00 2109.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 59.50 5259.39 88.39
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 103 180.50 13540.39 75.02
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 81 3832.00 3256.85 0.85
Subtotal (Total Children Is Unduplicated) 81 3832.00 3256.85 0.85
----------------------------------------------------------------------------------------------------------------
Total 4730.25 42909.99 9.07
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 166
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 165 120.00 4562.75 0.00
P 403 2942.38 14299.06 14010.30
D 3 3.50 129.50 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
670 1664.37 23918.68 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1241 4730.25 42909.99 14010.30