CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 1 5.50 203.50 37.00
Subtotal (Total Children Is Unduplicated) 1 5.50 203.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.00 1665.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 12.00 900.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 18 43.00 2615.00 60.81
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.25 356.37 67.88
Subtotal (Total Children Is Unduplicated) 2 9.75 661.83 67.88
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Total 58.25 3480.33 59.75
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Number of Children (Unduplicated) With at Least One Service 20
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Center 07
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 8 12.25 716.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
25 46.00 2764.08 0.00
Other 0 0.00 0.00 0.00
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Total 33 58.25 3480.33 0.00