CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 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 103 159.50 5901.50 37.00
Subtotal (Total Children Is Unduplicated) 103 159.50 5901.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.50 412.50 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 7 7.50 416.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 19.50 1462.50 75.00
Subtotal (Total Children Is Unduplicated) 25 39.00 2778.75 71.25
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 13.00 650.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 5.50 373.34 67.88
Subtotal (Total Children Is Unduplicated) 7 18.50 1023.34 55.32
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Total 217.00 9703.59 44.72
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Number of Children (Unduplicated) With at Least One Service 106
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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 53 32.25 1193.25 0.00
P 0 0.00 0.00 0.00
D 16 13.00 481.00 0.00
S 52 35.75 1322.75 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
23 19.25 973.09 0.00
Other 157 115.75 5658.50 0.00
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Total 302 217.00 9703.59 0.00