CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 342 868.75 32079.00 36.93
Subtotal (Total Children Is Unduplicated) 342 868.75 32079.00 36.93
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.50 1312.50 70.95
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.50 1162.50 70.45
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 38.00 2025.75 53.31
Subtotal (Total Children Is Unduplicated) 29 78.50 4913.25 62.59
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Total 947.25 36992.25 39.05
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Number of Children (Unduplicated) With at Least One Service 343
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Center 02
Flag Claims Units Chgs Paid
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R 34 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 953 793.25 29285.50 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
86 132.50 6911.25 0.00
Other 0 0.00 0.00 0.00
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Total 1073 947.25 36992.25 0.00