CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 878 1037.50 38369.00 36.98
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 856 1544.25 57091.00 36.97
TCM-T1017TL-TARGETED CASE MANAGEMENT 642 4886.50 180634.00 36.97
Subtotal (Total Children Is Unduplicated) 1225 7468.25 276094.00 36.97
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 100.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 55.50 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 3.50 186.00 53.14
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 64.50 4837.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 283.50 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 87 133.00 9322.39 70.09
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 4.50 150.00 33.33
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 85.00 4250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 352.50 22557.24 63.99
SPL-92508-GROUP SPL SESSION PER CHILD 8 31.00 409.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 51 6209.00 3171.00 0.51
Subtotal (Total Children Is Unduplicated) 68 6682.00 30537.44 4.57
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Total 14283.25 315953.83 22.12
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Number of Children (Unduplicated) With at Least One Service 1230
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Center 51
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 1 0.50 18.50 0.00
P 3 389.50 354.50 354.50
D 124 76.50 3056.62 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
12967 13816.75 312524.21 0.00
Other 0 0.00 0.00 0.00
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Total 13095 14283.25 315953.83 354.50