CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1121 6994.75 256502.50 36.67
Subtotal (Total Children Is Unduplicated) 1121 6994.75 256502.50 36.67
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 15.50 1162.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 45 62.50 4687.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 33.50 1859.25 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 53.50 4012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 93.00 5161.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 172 227.00 16912.50 74.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 273 491.00 34239.75 69.73
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 121 1041.75 52063.00 49.98
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 3.75 254.55 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 126 1056.50 52867.55 50.04
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Total 8542.25 343609.80 40.22
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Number of Children (Unduplicated) With at Least One Service 1123
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Center 54
Flag Claims Units Chgs Paid
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R 17 11.25 407.00 0.00
U 0 0.00 0.00 0.00
B 4077 2717.00 102439.23 0.00
P 7187 4811.50 188663.25 225868.61
D 11 8.25 318.25 0.00
S 1 0.75 27.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
973 993.50 51754.32 0.00
Other 0 0.00 0.00 0.00
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Total 12266 8542.25 343609.80 225868.61