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:Program Patients
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 164 409.00 15113.75 36.95
Subtotal (Total Children Is Unduplicated) 164 413.25 15234.00 36.86
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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 5 8.50 637.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 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 2 5.00 277.50 55.50
Subtotal (Total Children Is Unduplicated) 9 24.50 1740.00 71.02
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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 479.75 19824.96 41.32
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Number of Children (Unduplicated) With at Least One Service 178
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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
549 479.75 19824.96 0.00
Other 0 0.00 0.00 0.00
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Total 549 479.75 19824.96 0.00