CMS/EIP Fiscal Report Center: 51
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 11 57.00 2109.00 37.00
Subtotal (Total Children Is Unduplicated) 11 57.00 2109.00 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-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 3 4.00 273.50 68.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.00 500.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 23.50 1595.18 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 36.00 2443.68 67.88
Subtotal (Total Children Is Unduplicated) 7 69.50 4538.86 65.31
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Total 130.50 6921.36 53.04
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Number of Children (Unduplicated) With at Least One Service 11
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Center 51
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 87 58.00 2184.00 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
34 72.50 4737.36 0.00
Other 0 0.00 0.00 0.00
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Total 121 130.50 6921.36 0.00