CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 35 15.75 582.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 24 24.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 7.75 286.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 204.50 7566.50 37.00
Subtotal (Total Children Is Unduplicated) 58 252.00 8436.00 33.48
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 9.00 451.35 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 14 14.00 700.00 50.00
Subtotal (Total Children Is Unduplicated) 19 35.00 1910.81 54.59
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 120.00 60.00 0.50
Subtotal (Total Children Is Unduplicated) 1 131.75 701.14 5.32
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Total 418.75 11047.95 26.38
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Number of Children (Unduplicated) With at Least One Service 59
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Center 05
Flag Claims Units Chgs Paid
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R 13 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 315 187.00 6919.00 0.00
P 6 128.75 497.50 497.50
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
148 90.00 2935.44 0.00
Other 0 0.00 0.00 0.00
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Total 482 418.75 11047.95 497.50