CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 365 270.50 10008.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 299 410.25 15179.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 333 1242.00 45932.25 36.98
Subtotal (Total Children Is Unduplicated) 627 1922.75 71120.00 36.99
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 7.00 525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.00 525.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 7.00 283.50 40.50
Subtotal (Total Children Is Unduplicated) 15 27.00 1783.50 66.06
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 82.00 5566.16 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 15 1507.00 753.50 0.50
Subtotal (Total Children Is Unduplicated) 15 1589.00 6319.66 3.98
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Total 3538.75 79223.16 22.39
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Number of Children (Unduplicated) With at Least One Service 630
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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 0 0.00 0.00 0.00
D 13 8.00 303.00 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
3376 3530.75 78920.16 0.00
Other 0 0.00 0.00 0.00
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Total 3389 3538.75 79223.16 0.00