CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 1102 4161.50 153975.50 37.00
Subtotal (Total Children Is Unduplicated) 1102 4161.50 153975.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 34.50 2587.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 16.00 1200.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 20.00 1110.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 144 246.00 18450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 143.50 10762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 139.00 10425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 114.00 6327.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 124.00 9300.00 75.00
Subtotal (Total Children Is Unduplicated) 228 865.50 62299.50 71.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 55.00 2750.00 50.00
Subtotal (Total Children Is Unduplicated) 8 55.00 2750.00 50.00
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Total 5082.00 219025.00 43.10
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Number of Children (Unduplicated) With at Least One Service 1108
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Center 10
Flag Claims Units Chgs Paid
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R 5 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 6561 4180.50 155745.50 0.00
P 614 899.75 63214.75 63255.50
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 7180 5082.00 219025.00 63255.50