CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 397 313.75 11608.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 296 410.00 15170.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 797 3386.25 125272.75 36.99
Subtotal (Total Children Is Unduplicated) 818 4110.00 152051.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 25.00 1800.00 72.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 8.00 600.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 202.50 40.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 42 62.50 4175.00 66.80
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 0.75 37.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 81.75 5549.19 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 1245.00 622.50 0.50
Subtotal (Total Children Is Unduplicated) 19 1328.50 6259.19 4.71
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Total 5501.00 162485.69 29.54
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Number of Children (Unduplicated) With at Least One Service 820
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Center 51
Flag Claims Units Chgs Paid
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R 4 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 2983 2098.50 78973.60 0.00
P 1 45.00 22.50 22.50
D 13 10.75 442.75 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
3550 3343.50 82869.59 0.00
Other 1 1.50 112.50 0.00
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Total 6552 5501.00 162485.69 22.50