CMS/EIP Fiscal Report Center: 55
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 305 868.75 32023.50 36.86
Subtotal (Total Children Is Unduplicated) 305 868.75 32023.50 36.86
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 61.50 4612.50 75.00
Subtotal (Total Children Is Unduplicated) 41 61.50 4612.50 75.00
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 1 1.50 101.82 67.88
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Total 931.75 36737.82 39.43
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Number of Children (Unduplicated) With at Least One Service 305
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Center 55
Flag Claims Units Chgs Paid
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R 5 4.75 175.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 914 898.75 35413.50 35413.50
D 1 1.00 37.00 0.00
S 2 2.25 83.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
28 25.00 1028.32 0.00
Other 0 0.00 0.00 0.00
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Total 950 931.75 36737.82 35413.50