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: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 473 2055.25 75962.00 36.96
Subtotal (Total Children Is Unduplicated) 473 2055.25 75962.00 36.96
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.00 1275.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 8.00 600.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 11.00 825.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 5.00 202.50 40.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 22 42.00 2951.00 70.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 19.00 1289.72 67.88
Subtotal (Total Children Is Unduplicated) 11 32.00 1939.72 60.62
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Total 2129.25 80852.72 37.97
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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 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 3114 2125.75 80685.22 0.00
P 1 0.25 9.25 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 2.25 121.25 0.00
Other 0 0.00 0.00 0.00
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Total 3120 2129.25 80852.72 0.00