CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 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 34 12.75 471.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 15.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 12.00 444.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 63 171.25 6336.25 37.00
Subtotal (Total Children Is Unduplicated) 63 211.00 7252.00 34.37
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 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 4 4.00 291.12 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 7.00 351.05 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 12 28.00 1742.17 62.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.50 325.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.50 101.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 165.00 82.50 0.50
Subtotal (Total Children Is Unduplicated) 1 174.00 577.20 3.32
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Total 413.00 9571.37 23.18
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Number of Children (Unduplicated) With at Least One Service 63
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Center 05
Flag Claims Units Chgs Paid
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R 7 7.00 423.08 0.00
U 0 0.00 0.00 0.00
B 295 159.00 5883.00 0.00
P 6 171.50 407.50 407.50
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
126 75.50 2857.79 0.00
Other 0 0.00 0.00 0.00
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Total 434 413.00 9571.37 407.50