CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 49 48.75 1803.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 58 59.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 28 29.50 1091.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 72 630.50 23328.50 37.00
Subtotal (Total Children Is Unduplicated) 72 767.75 26223.75 34.16
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 17 22.00 1100.00 50.00
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
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 22 22.00 1637.54 74.43
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 22 27.00 1429.29 52.94
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 25 30.00 1500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 40 120.00 6853.33 57.11
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.75 37.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 29.50 1475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 6.00 407.28 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.50 576.98 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 705.00 352.50 0.50
Subtotal (Total Children Is Unduplicated) 1 751.25 2924.26 3.89
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Total 1639.00 36001.34 21.97
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Number of Children (Unduplicated) With at Least One Service 72
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Center 05
Flag Claims Units Chgs Paid
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R 20 20.00 1119.09 0.00
U 0 0.00 0.00 0.00
B 1061 611.00 23174.02 200.00
P 26 736.75 1940.00 1940.00
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
459 271.25 9768.23 0.00
Other 0 0.00 0.00 0.00
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Total 1566 1639.00 36001.34 2140.00