CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 82 287.50 10637.50 37.00
Subtotal (Total Children Is Unduplicated) 82 287.50 10637.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 337.50 67.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 9.50 712.50 75.00
Subtotal (Total Children Is Unduplicated) 22 40.00 2562.75 64.07
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.50 175.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.50 175.00 50.00
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Total 331.00 13375.25 40.41
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Number of Children (Unduplicated) With at Least One Service 82
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Center 01
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 74 66.25 2451.25 0.00
H 2 3.00 195.75 0.00
T 10 12.50 801.00 801.00
22 25.00 1413.25 0.00
Other 287 224.25 8514.00 0.00
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Total 395 331.00 13375.25 801.00