CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 743 2292.00 84665.25 36.94
Subtotal (Total Children Is Unduplicated) 743 2292.00 84665.25 36.94
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 13.00 975.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 20.00 1500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 37.50 2081.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 56.50 4237.50 75.00
Subtotal (Total Children Is Unduplicated) 93 136.50 9488.00 69.51
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 72 424.00 21200.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 74 427.00 21385.76 50.08
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Total 2855.50 115539.01 40.46
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Number of Children (Unduplicated) With at Least One Service 762
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Center 54
Flag Claims Units Chgs Paid
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R 6 3.25 120.25 0.00
U 0 0.00 0.00 0.00
B 100 96.75 5360.01 0.00
P 3964 2755.50 110058.75 110049.50
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 4070 2855.50 115539.01 110049.50