CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 347 923.75 33799.50 36.59
Subtotal (Total Children Is Unduplicated) 347 923.75 33799.50 36.59
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 43.50 3262.50 75.00
Subtotal (Total Children Is Unduplicated) 30 45.00 3375.00 75.00
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 1 2.00 135.76 67.88
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Total 970.75 37310.26 38.43
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Number of Children (Unduplicated) With at Least One Service 347
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Center 55
Flag Claims Units Chgs Paid
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R 20 22.25 824.75 0.00
U 0 0.00 0.00 0.00
B 247 207.25 7437.00 0.00
P 808 731.25 28616.75 28607.50
D 0 0.00 0.00 0.00
S 2 2.50 92.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
11 7.50 339.26 0.00
Other 0 0.00 0.00 0.00
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Total 1088 970.75 37310.26 28607.50