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:Not Part C
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 240 1151.50 42050.50 36.52
Subtotal (Total Children Is Unduplicated) 240 1151.50 42050.50 36.52
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 11.00 825.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 14.50 804.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 11.50 862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 34.00 2550.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 87.50 4856.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 115.00 8625.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 147 288.00 19558.00 67.91
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 2 7.00 350.00 50.00
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Total 1446.50 61958.50 42.83
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Number of Children (Unduplicated) With at Least One Service 254
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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 575 414.50 15847.50 0.00
P 1079 837.50 33913.75 33715.75
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
170 194.50 12197.25 0.00
Other 0 0.00 0.00 0.00
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Total 1824 1446.50 61958.50 33715.75