CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
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
CASE-CASE-NON-TCM CASE MANAGEMENT 10 4.75 175.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 17.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 15 22.00 814.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 13.75 508.75 37.00
Subtotal (Total Children Is Unduplicated) 23 57.50 1498.50 26.06
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
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 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 9 11.00 694.00 63.09
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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 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 59.00 4004.92 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 48.50 3292.18 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 51.00 3461.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 3039.00 2818.90 0.93
Subtotal (Total Children Is Unduplicated) 15 3200.75 13709.13 4.28
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Total 3269.25 15901.63 4.86
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Number of Children (Unduplicated) With at Least One Service 23
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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 0 0.00 0.00 0.00
P 70 2706.50 13825.13 13825.13
D 14 5.50 203.50 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
96 557.25 1873.00 0.00
Other 0 0.00 0.00 0.00
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Total 180 3269.25 15901.63 13825.13