CMS/EIP Fiscal Report Center: 54
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 11 18.00 666.00 37.00
Subtotal (Total Children Is Unduplicated) 11 18.00 666.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 2 4.00 280.50 70.13
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 1 4.00 271.52 67.88
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Total 26.00 1218.02 46.85
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Number of Children (Unduplicated) With at Least One Service 11
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Center 54
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 23 12.50 462.50 0.00
P 8 5.50 203.50 203.50
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
5 8.00 552.02 0.00
Other 0 0.00 0.00 0.00
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Total 36 26.00 1218.02 203.50