CMS/EIP Fiscal Report Center: 05
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 60 159.00 5883.00 37.00
Subtotal (Total Children Is Unduplicated) 60 159.00 5883.00 37.00
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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
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 300.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 7 18.00 1196.16 66.45
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 1 2.50 169.70 67.88
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Total 179.50 7248.86 40.38
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Number of Children (Unduplicated) With at Least One Service 60
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Center 05
Flag Claims Units Chgs Paid
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R 7 7.00 423.08 0.00
U 0 0.00 0.00 0.00
B 295 159.00 5883.00 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
16 13.50 942.78 0.00
Other 0 0.00 0.00 0.00
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Total 318 179.50 7248.86 0.00