CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 89 219.75 8130.75 37.00
Subtotal (Total Children Is Unduplicated) 89 221.50 8158.50 36.83
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.50 1087.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 11 19.50 1462.50 75.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 15.00 1018.20 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 11.00 746.68 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 10.00 678.80 67.88
Subtotal (Total Children Is Unduplicated) 6 47.00 2993.68 63.70
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Total 288.00 12614.68 43.80
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Number of Children (Unduplicated) With at Least One Service 105
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Center 09
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 5 19.00 1128.80 1128.80
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
300 269.00 11485.88 0.00
Other 0 0.00 0.00 0.00
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Total 305 288.00 12614.68 1128.80