CMS/EIP Fiscal Report Center: 54
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 20 93.50 3450.25 36.90
Subtotal (Total Children Is Unduplicated) 20 93.50 3450.25 36.90
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 150.00 60.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.00 55.50 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 13 15.50 1013.50 65.39
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 14.50 984.26 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 14.50 984.26 67.88
Subtotal (Total Children Is Unduplicated) 2 31.50 2138.22 67.88
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Total 140.50 6601.97 46.99
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Number of Children (Unduplicated) With at Least One Service 22
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Center 54
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 70 35.25 1304.25 0.00
P 125 62.25 2426.50 2426.50
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
23 43.00 2871.22 0.00
Other 0 0.00 0.00 0.00
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Total 218 140.50 6601.97 2426.50