CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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 382 258.25 9546.00 36.96
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 322 427.00 15799.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 790 3282.75 121393.75 36.98
Subtotal (Total Children Is Unduplicated) 808 3968.00 146738.75 36.98
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Screening, Eval, and Assessment,Class #02
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 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 16.50 1237.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 6.00 450.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 19.00 1425.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 202.50 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 28 52.50 3727.77 71.01
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 25.00 12.50
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 55.00 2750.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 79.00 4542.32 57.50
SPL-92508-GROUP SPL SESSION PER CHILD 8 31.00 409.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 15 1363.00 680.00 0.50
Subtotal (Total Children Is Unduplicated) 30 1530.00 8406.52 5.49
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Total 5550.50 158873.04 28.62
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Number of Children (Unduplicated) With at Least One Service 808
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Center 51
Flag Claims Units Chgs Paid
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R 2 2.00 150.00 0.00
U 0 0.00 0.00 0.00
B 2983 2057.50 77672.80 0.00
P 1 217.00 108.50 108.50
D 23 13.25 497.25 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
3371 3260.75 80444.49 0.00
Other 0 0.00 0.00 0.00
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Total 6380 5550.50 158873.04 108.50