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: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 474 1981.00 73229.00 36.97
Subtotal (Total Children Is Unduplicated) 474 1981.00 73229.00 36.97
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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-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 9 12.50 937.50 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 9 9.00 675.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 40.50 40.50
Subtotal (Total Children Is Unduplicated) 17 29.50 2178.00 73.83
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 50.00 2500.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.00 352.60 58.77
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 16 57.00 2865.80 50.28
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Total 2067.50 78272.80 37.86
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Number of Children (Unduplicated) With at Least One Service 476
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 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
3 8.00 450.00 0.00
Other 0 0.00 0.00 0.00
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Total 2988 2067.50 78272.80 0.00