CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 124 214.00 7918.00 37.00
Subtotal (Total Children Is Unduplicated) 124 214.00 7918.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 13.50 1012.50 75.00
Subtotal (Total Children Is Unduplicated) 17 24.00 1712.25 71.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 8.00 400.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 5.00 339.40 67.88
Subtotal (Total Children Is Unduplicated) 5 13.00 739.40 56.88
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Total 251.00 10369.65 41.31
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Number of Children (Unduplicated) With at Least One Service 125
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Center 01
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 40 27.00 999.00 0.00
H 0 0.00 0.00 0.00
T 19 19.00 1306.75 1306.75
14 13.00 700.40 0.00
Other 347 192.00 7363.50 0.00
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Total 420 251.00 10369.65 1306.75