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: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 68 306.50 11340.50 37.00
Subtotal (Total Children Is Unduplicated) 68 306.50 11340.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 14.00 777.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.50 337.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.00 3515.00 185.00
Subtotal (Total Children Is Unduplicated) 33 46.50 5304.50 114.08
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Total 353.00 16645.00 47.15
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Number of Children (Unduplicated) With at Least One Service 68
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Center 04
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 213 307.50 11508.00 0.00
P 24 18.50 1529.50 1258.81
D 5 5.00 277.50 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
19 22.00 3330.00 0.00
Other 0 0.00 0.00 0.00
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Total 261 353.00 16645.00 1258.81