CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 133 65.50 2423.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 228 295.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 69.75 2580.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 604 1653.25 61151.75 36.99
TCON-TCON-TRANSITION CONFERENCE 56 56.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 607 2139.50 66156.00 30.92
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 3.00 375.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 60 90.50 4525.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 109.50 8137.50 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 65.00 4875.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 46.50 2580.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 46.50 3487.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 18.00 873.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.00 873.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 191 473.50 30326.25 64.05
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 88.00 4400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 295.25 14762.50 50.00
INTR-INTR-INTERPRETER 1 2.00 84.00 42.00
OCCT-97530-OT SESSION BY LICENSED OT 139 673.60 45642.60 67.76
OCCT-97530HM-OT SESSION BY OT ASST 9 39.25 2119.10 53.99
PHY-97110-PT SESSION BY LICENSED PT 84 359.06 24320.07 67.73
PHY-97110HM-PT SESSION BY PT ASST 15 34.94 1898.46 54.33
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1331.72 88244.83 66.26
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 238 49088.0 37972.10 0.77
Subtotal (Total Children Is Unduplicated) 334 51914.3 219531.86 4.23
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Total 54527.32 316014.11 5.80
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Number of Children (Unduplicated) With at Least One Service 708
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Center 55
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 129 154.75 6181.75 0.00
P 5216 51480.78 169660.95 169660.95
D 11 10.75 474.25 55.50
S 11 12.75 471.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3589 2868.29 139225.41 0.00
Other 0 0.00 0.00 0.00
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Total 8956 54527.32 316014.11 169716.45