CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.00 148.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 19.00 703.00 37.00
Subtotal (Total Children Is Unduplicated) 12 26.00 851.00 32.73
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 4 6.00 411.00 68.50
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 11.00 746.68 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 3.00 203.64 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.00 543.04 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 893.00 759.05 0.85
Subtotal (Total Children Is Unduplicated) 6 917.25 2333.66 2.54
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Total 949.25 3595.66 3.79
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Number of Children (Unduplicated) With at Least One Service 14
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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 23 12.50 462.50 0.00
P 22 864.00 1966.93 1966.93
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
21 72.75 1166.23 0.00
Other 0 0.00 0.00 0.00
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Total 66 949.25 3595.66 1966.93