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: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 477 2057.25 76118.25 37.00
Subtotal (Total Children Is Unduplicated) 477 2057.25 76118.25 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 8 12.00 825.00 68.75
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 225.00 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 3 3.00 225.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 40.50 40.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 16 24.50 1675.00 68.37
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 0.75 37.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.00 1357.60 67.88
Subtotal (Total Children Is Unduplicated) 5 20.75 1395.10 67.23
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Total 2102.50 79188.35 37.66
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Number of Children (Unduplicated) With at Least One Service 478
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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 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
1 0.75 37.50 0.00
Other 1 1.50 112.50 0.00
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Total 2989 2102.50 79188.35 0.00