CMS/EIP Fiscal Report Center: 55
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 17 8.00 296.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 25 27.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 8.25 305.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 62 246.50 9074.25 36.81
Subtotal (Total Children Is Unduplicated) 62 289.75 9675.50 33.39
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.50 225.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 52.50 3937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.50 1687.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.50 787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 31.50 1748.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.50 1387.50 75.00
Subtotal (Total Children Is Unduplicated) 38 140.00 9773.25 69.81
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Total 429.75 19448.75 45.26
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Number of Children (Unduplicated) With at Least One Service 62
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Center 55
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 3 4.50 337.50 0.00
P 141 180.47 8133.06 8133.06
D 5 3.75 195.75 0.00
S 5 7.00 259.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
220 233.03 10486.44 0.00
Other 1 0.50 18.50 0.00
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Total 376 429.75 19448.75 8133.06