CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 590 1743.25 63732.50 36.56
Subtotal (Total Children Is Unduplicated) 590 1743.25 63732.50 36.56
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 34.00 1887.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 41.00 3037.50 74.09
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 61 115.00 7728.00 67.20
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 61 344.25 17212.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 1.50 101.82 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 65 350.75 17564.32 50.08
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Total 2209.00 89024.82 40.30
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Number of Children (Unduplicated) With at Least One Service 598
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Center 54
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 1962 1351.25 51931.00 0.00
P 696 468.00 17214.25 17204.25
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
393 389.75 19879.57 0.00
Other 0 0.00 0.00 0.00
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Total 3051 2209.00 89024.82 17204.25