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
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 397 313.75 11608.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 296 410.00 15170.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 340 1329.00 49154.50 36.99
Subtotal (Total Children Is Unduplicated) 654 2052.75 75933.25 36.99
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 12.00 900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 162.00 40.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 27 36.00 2376.50 66.01
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 56.75 3852.19 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 1245.00 622.50 0.50
Subtotal (Total Children Is Unduplicated) 19 1302.75 4524.69 3.47
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Total 3391.50 82834.44 24.42
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Number of Children (Unduplicated) With at Least One Service 659
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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 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
3542 3335.75 82369.19 0.00
Other 0 0.00 0.00 0.00
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Total 3556 3391.50 82834.44 22.50