CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3 3.00 0.00 0.00
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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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 7.00 388.50 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 561.50 46.79
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 23.00 1115.50 48.50
Subtotal (Total Children Is Unduplicated) 45 58.50 3059.00 52.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 20.00 1000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 43 390.00 26374.64 67.63
OCCT-97530HM-OT SESSION BY OT ASST 2 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 66 562.50 37836.18 67.26
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 599.75 39619.77 66.06
SPL-92508-GROUP SPL SESSION PER CHILD 11 40.00 692.04 17.30
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 150.00 75.00 0.50
Subtotal (Total Children Is Unduplicated) 141 1767.25 105869.23 59.91
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Total 1828.75 108928.23 59.56
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Number of Children (Unduplicated) With at Least One Service 151
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Center 57
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 2 152.00 210.76 210.76
H 0 0.00 0.00 0.00
T 3 9.50 501.82 501.82
699 1667.25 108215.65 50744.44
Other 0 0.00 0.00 0.00
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Total 704 1828.75 108928.23 51457.02