CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 4.00 148.00 37.00
Subtotal (Total Children Is Unduplicated) 3 4.00 148.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 15.25 1105.00 72.46
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 13 19.00 1023.75 53.88
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 38 57.75 3431.25 59.42
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.00 120.00 24.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 117 484.50 24141.63 49.83
OCCT-97530-OT SESSION BY LICENSED OT 29 137.50 9333.50 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 15.00 814.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 54 330.75 22448.90 67.87
PHY-97110HM-PT SESSION BY PT ASST 3 51.75 2811.06 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 121 613.50 41579.89 67.77
Subtotal (Total Children Is Unduplicated) 246 1638.00 101249.78 61.81
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Total 1699.75 104829.03 61.67
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Number of Children (Unduplicated) With at Least One Service 271
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Center 01
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 0 0.00 0.00 0.00
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
555 1545.25 94923.38 0.00
Other 152 154.50 9905.65 0.00
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Total 707 1699.75 104829.03 0.00