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:Not Part C
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 242 1219.50 45121.50 37.00
Subtotal (Total Children Is Unduplicated) 242 1219.50 45121.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.50 900.00 72.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 52.00 3900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 27.50 2062.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 101.50 5625.00 55.42
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 46.00 3450.00 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 133 250.50 16628.75 66.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.50 575.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 2 13.50 710.76 52.65
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Total 1483.50 62461.01 42.10
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Number of Children (Unduplicated) With at Least One Service 243
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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 323 292.50 12620.75 0.00
P 445 338.50 13688.26 13696.51
D 114 106.75 3949.75 0.00
S 108 116.50 4310.50 0.00
H 2 3.00 195.75 0.00
T 10 12.50 801.00 801.00
75 100.00 6588.75 0.00
Other 579 513.75 20306.25 0.00
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Total 1656 1483.50 62461.01 14497.51