CMS/EIP Fiscal Report Center: 55
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 74 32.50 1202.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 108 126.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 121 89.50 3311.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 176 1108.75 40903.50 36.89
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 176 1357.75 45417.50 33.45
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 17 27.00 1350.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.68 200.94 74.98
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 117 227.00 17025.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 121.82 9136.56 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 27.50 2062.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 101.50 5633.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 48.00 3600.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 154 564.50 39617.75 70.18
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.28 155.47 68.19
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 60.00 40.00 0.67
Subtotal (Total Children Is Unduplicated) 2 62.28 195.47 3.14
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Total 1984.53 85230.72 42.95
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Number of Children (Unduplicated) With at Least One Service 176
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Center 55
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 12 15.00 1049.00 0.00
P 615 821.36 35852.22 35852.22
D 14 13.75 718.75 0.00
S 10 13.50 556.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1097 1119.92 47017.25 0.00
Other 1 0.50 18.50 0.00
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Total 1750 1984.53 85230.72 35852.22