CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
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 408 225.50 8343.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 350 442.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 268 203.25 7520.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 393 1029.50 37619.75 36.54
TCON-TCON-TRANSITION CONFERENCE 56 57.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 657 1957.25 53483.50 27.33
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 8 9.00 450.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 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 6 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 18 30.00 1760.25 58.68
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 16 14.00 700.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 15 10.25 512.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 92.25 4612.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 12.75 865.47 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 9.75 661.83 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 38.50 2613.38 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 183 21870.5 10935.27 0.50
Subtotal (Total Children Is Unduplicated) 183 22051.8 21069.70 0.96
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Total 24039.04 76313.45 3.17
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Number of Children (Unduplicated) With at Least One Service 670
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Center 52
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
4136 24039.04 76313.45 0.00
Other 0 0.00 0.00 0.00
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Total 4136 24039.04 76313.45 0.00