CMS/EIP Fiscal Report Center: 54
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 654 1978.50 73075.00 36.93
Subtotal (Total Children Is Unduplicated) 654 1978.50 73075.00 36.93
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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 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 10.50 787.50 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 15 19.00 1054.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 32.50 2437.50 75.00
Subtotal (Total Children Is Unduplicated) 64 88.50 6248.75 70.61
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 71 426.00 21300.00 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) 73 429.00 21485.76 50.08
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Total 2496.00 100809.51 40.39
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Number of Children (Unduplicated) With at Least One Service 672
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Center 54
Flag Claims Units Chgs Paid
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R 4 2.50 92.50 0.00
U 0 0.00 0.00 0.00
B 94 89.00 4788.26 0.00
P 3508 2390.75 95210.00 95200.75
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 1 0.25 9.25 0.00
16 13.50 709.50 0.00
Other 0 0.00 0.00 0.00
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Total 3623 2496.00 100809.51 95200.75