CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 814 3403.75 125494.75 36.87
Subtotal (Total Children Is Unduplicated) 814 3403.75 125494.75 36.87
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 101.00 7537.50 74.63
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 50.00 3712.50 74.25
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 65.00 4762.50 73.27
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 117 174.00 9462.75 54.38
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.50 712.50 75.00
Subtotal (Total Children Is Unduplicated) 149 400.50 26262.75 65.57
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
Subtotal (Total Children Is Unduplicated) 4 4.00 222.20 55.55
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Total 3808.25 151979.70 39.91
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Number of Children (Unduplicated) With at Least One Service 814
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Center 02
Flag Claims Units Chgs Paid
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R 16 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 3874 3017.25 111323.75 0.00
P 0 0.00 0.00 0.00
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
594 777.75 40165.70 0.00
Other 0 0.00 0.00 0.00
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Total 4484 3808.25 151979.70 0.00