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:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 826 7210.50 266655.75 36.98
Subtotal (Total Children Is Unduplicated) 826 7210.50 266655.75 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 16.50 1237.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 35.50 2662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.00 525.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 63.00 4725.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 121.50 40.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 236.53 78.84
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 89 140.00 10275.53 73.40
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 227.50 11375.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 29.00 1804.48 62.22
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 35 259.50 13219.08 50.94
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Total 7610.00 290150.36 38.13
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Number of Children (Unduplicated) With at Least One Service 827
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Center 51
Flag Claims Units Chgs Paid
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R 3 3.00 187.00 0.00
U 0 0.00 0.00 0.00
B 11371 7590.50 289013.86 0.00
P 0 0.00 0.00 0.00
D 1 1.00 75.00 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
8 15.50 874.50 0.00
Other 0 0.00 0.00 0.00
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Total 11383 7610.00 290150.36 0.00