CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 225 752.00 27824.00 37.00
Subtotal (Total Children Is Unduplicated) 225 752.00 27824.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 29.00 2175.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 28.50 1581.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 67.50 5062.50 75.00
Subtotal (Total Children Is Unduplicated) 78 156.50 10879.50 69.52
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 41.00 2033.25 49.59
PHY-97110-PT SESSION BY LICENSED PT 2 19.50 1323.55 67.87
Subtotal (Total Children Is Unduplicated) 10 60.50 3356.80 55.48
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Total 969.00 42060.30 43.41
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Number of Children (Unduplicated) With at Least One Service 225
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Center 01
Flag Claims Units Chgs Paid
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R 2 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 229 164.00 8656.50 0.00
P 332 192.75 7340.00 7293.75
D 129 72.00 2664.00 0.00
S 87 74.50 2870.00 0.00
H 1 1.00 75.00 0.00
T 14 14.00 995.75 995.75
49 55.50 3149.05 0.00
Other 665 394.75 16291.50 0.00
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Total 1508 969.00 42060.30 8289.50