CMS/EIP Fiscal Report Center: 54
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 10 4.75 175.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 17.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 15 22.00 814.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 107.25 3959.00 36.91
Subtotal (Total Children Is Unduplicated) 25 151.00 4948.75 32.77
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 412.50 103.13
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 19 28.00 1970.00 70.36
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 86.00 5837.68 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 51.00 3461.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 65.50 4446.14 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 3039.00 2818.90 0.93
Subtotal (Total Children Is Unduplicated) 15 3244.75 16695.85 5.15
----------------------------------------------------------------------------------------------------------------
Total 3423.75 23614.60 6.90
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 70 35.25 1304.25 0.00
P 195 2768.75 16251.63 16251.63
D 14 5.50 203.50 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
123 614.25 5855.22 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 402 3423.75 23614.60 16251.63