CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 54 148.75 5485.25 36.88
Subtotal (Total Children Is Unduplicated) 54 148.75 5485.25 36.88
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 2 2.50 278.00 111.20
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 1 9.00 450.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 160.25 6213.25 38.77
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 54
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 190 148.75 5485.25 0.00
P 2 1.50 222.50 100.28
D 1 1.00 55.50 0.00
S 0 0.00 0.00 0.00
H 3 9.00 450.00 450.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 196 160.25 6213.25 550.28