CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Eligibility Filter:Not Part C
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 38 19.00 703.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 72 69.75 2580.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 91 558.50 20664.50 37.00
Subtotal (Total Children Is Unduplicated) 91 649.25 23948.25 36.89
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 36.44 2428.04 66.63
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 46.00 2553.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 55 114.94 7167.79 62.36
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.75 75.00 100.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 10.00 500.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 10.32 582.46 56.44
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 39 1755.00 877.50 0.50
Subtotal (Total Children Is Unduplicated) 40 1779.07 2184.96 1.23
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Total 2543.26 33301.00 13.09
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Number of Children (Unduplicated) With at Least One Service 91
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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 341 222.50 8232.50 0.00
P 117 1653.26 5950.49 5950.49
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
696 667.50 19118.01 0.00
Other 0 0.00 0.00 0.00
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Total 1154 2543.26 33301.00 5950.49