CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
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
CASE-CASE-NON-TCM CASE MANAGEMENT 4 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.75 64.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 147 368.75 13624.50 36.95
Subtotal (Total Children Is Unduplicated) 147 373.00 13744.75 36.85
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 3.00 166.50 55.50
Subtotal (Total Children Is Unduplicated) 6 16.50 1179.00 71.45
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 4 19.00 1289.72 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 12.50 848.50 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 10.50 712.74 67.88
Subtotal (Total Children Is Unduplicated) 7 42.00 2850.96 67.88
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Total 431.50 17774.71 41.19
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Number of Children (Unduplicated) With at Least One Service 158
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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 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
520 431.50 17774.71 0.00
Other 0 0.00 0.00 0.00
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Total 520 431.50 17774.71 0.00