CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 351 1033.00 38054.50 36.84
Subtotal (Total Children Is Unduplicated) 351 1033.00 38054.50 36.84
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 61.50 4612.50 75.00
Subtotal (Total Children Is Unduplicated) 62 65.00 4925.00 75.77
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 3 7.50 455.46 60.73
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Total 1105.50 43434.96 39.29
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Number of Children (Unduplicated) With at Least One Service 352
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Center 55
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 2 1.00 37.00 0.00
P 1198 1094.25 42752.75 42715.25
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
15 9.75 626.71 0.00
Other 0 0.00 0.00 0.00
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Total 1216 1105.50 43434.96 42715.25