CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 682 392.75 14531.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 746 1355.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 827 1204.50 44566.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1244 9048.00 334729.75 36.99
Subtotal (Total Children Is Unduplicated) 1253 12000.3 393828.00 32.82
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 9.00 450.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 18.00 1350.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 18.00 1350.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.00 55.50 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.50 862.50 69.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 32 32.00 2474.48 77.33
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 9.00 488.97 54.33
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 17.00 850.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 50 133.50 8892.95 66.61
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.75 37.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.25 62.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.50 225.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 21.00 1425.48 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 2 31.50 2004.12 63.62
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Total 12165.25 404725.07 33.27
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Number of Children (Unduplicated) With at Least One Service 1253
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Center 05
Flag Claims Units Chgs Paid
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R 50 51.75 3552.70 0.00
U 0 0.00 0.00 0.00
B 7950 4217.50 156662.38 50.00
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
13418 7896.00 244509.99 0.00
Other 0 0.00 0.00 0.00
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Total 21418 12165.25 404725.07 50.00