CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 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 266 937.00 34669.00 37.00
Subtotal (Total Children Is Unduplicated) 266 937.00 34669.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 30.00 2250.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 10.50 787.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 21.50 1612.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 35.50 1970.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 23.00 1725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 33.00 2475.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 73.50 4079.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 83.50 6262.50 75.00
Subtotal (Total Children Is Unduplicated) 113 336.50 23112.00 68.68
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 2 4.00 253.64 63.41
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Total 1277.50 58034.64 45.43
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Number of Children (Unduplicated) With at Least One Service 268
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Center 10
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 820 757.50 31692.00 0.00
P 456 495.25 25334.25 25332.75
D 15 19.50 721.50 721.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3 3.00 203.64 0.00
Other 1 2.25 83.25 0.00
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Total 1295 1277.50 58034.64 26054.25