CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 311 794.00 29146.75 36.71
Subtotal (Total Children Is Unduplicated) 311 794.00 29146.75 36.71
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.00 1950.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 42.50 2358.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 37 98.50 6416.75 65.14
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 121.75 6087.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 27.00 1832.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 33.50 2273.98 67.88
Subtotal (Total Children Is Unduplicated) 43 182.25 10194.24 55.94
----------------------------------------------------------------------------------------------------------------
Total 1074.75 45757.74 42.58
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 312
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1674 1001.50 42795.17 0.00
P 121 63.50 2349.50 2349.50
D 0 0.00 0.00 0.00
S 1 0.25 9.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
14 9.50 603.82 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1810 1074.75 45757.74 2349.50