CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 2 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 3.00 166.50 55.50
Subtotal (Total Children Is Unduplicated) 4 13.00 916.50 70.50
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 10.50 712.74 67.88
Subtotal (Total Children Is Unduplicated) 3 10.50 712.74 67.88
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Total 396.50 15373.99 38.77
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Number of Children (Unduplicated) With at Least One Service 152
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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
506 396.50 15373.99 0.00
Other 0 0.00 0.00 0.00
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Total 506 396.50 15373.99 0.00