CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
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 259 101.50 3755.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 273 316.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 338 311.75 11534.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 400 1364.50 50477.25 36.99
Subtotal (Total Children Is Unduplicated) 612 2093.75 65767.50 31.41
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.50 133.25 53.30
EXIT-EXIT-TRANSITION ASSESSMENT 12 23.00 1150.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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 1 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 11 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 11.50 862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.08 39.00 18.75
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 56.50 3135.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.50 937.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 86 138.58 8075.03 58.27
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 1154.10 384.70
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 70 64.75 3237.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.25 6.25 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 176 171.00 8550.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 8 2.50 62.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 65 30.50 1525.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 3.00 75.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 70 33.50 1675.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 120 66.25 3312.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 47 193.50 9675.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 193 1004.00 50200.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 3.00 150.00 50.00
INTR-INTR-INTERPRETER 6 35.25 1762.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 37 151.79 8099.21 53.36
PHY-97110-PT SESSION BY LICENSED PT 21 74.83 3966.69 53.01
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 323.62 21655.65 66.92
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 14.50 787.64 54.32
TRAN-TRAN-FAMILY TRANSPORTATION 1 22.00 420.97 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 381 79643.0 39821.50 0.50
Subtotal (Total Children Is Unduplicated) 428 81841.2 156155.73 1.91
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Total 84073.57 229998.26 2.74
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Number of Children (Unduplicated) With at Least One Service 661
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Center 05
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 2613 61508.87 119344.98 119344.98
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
4555 22564.70 110653.28 0.00
Other 0 0.00 0.00 0.00
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Total 7168 84073.57 229998.26 119344.98