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
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 382 258.25 9546.00 36.96
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 322 427.00 15799.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 333 1301.75 48164.75 37.00
Subtotal (Total Children Is Unduplicated) 653 1987.00 73509.75 37.00
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 10.00 750.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 162.00 40.50
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 14 23.00 1549.77 67.38
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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 3 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 68.00 3850.32 56.62
SPL-92508-GROUP SPL SESSION PER CHILD 7 30.00 396.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 14 1326.00 661.50 0.50
Subtotal (Total Children Is Unduplicated) 17 1431.00 5182.82 3.62
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Total 3441.00 80242.34 23.32
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Number of Children (Unduplicated) With at Least One Service 655
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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 0 0.00 0.00 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
3360 3210.75 79636.59 0.00
Other 0 0.00 0.00 0.00
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Total 3384 3441.00 80242.34 108.50