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
Bill Flag Filter:RBPU
Eligibility Filter:All
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 672 1970.75 71900.25 36.48
Subtotal (Total Children Is Unduplicated) 672 1970.75 71900.25 36.48
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 15.50 860.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 18.50 1350.00 72.97
Subtotal (Total Children Is Unduplicated) 33 51.00 3426.75 67.19
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 36 99.00 4950.00 50.00
Subtotal (Total Children Is Unduplicated) 36 99.00 4950.00 50.00
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Total 2120.75 80277.00 37.85
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Number of Children (Unduplicated) With at Least One Service 678
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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 2253 1561.50 59779.00 0.00
P 806 559.25 20498.00 20395.50
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 3059 2120.75 80277.00 20395.50