CMS/EIP Fiscal Report Center: 52
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 36 97.25 3561.25 36.62
Subtotal (Total Children Is Unduplicated) 36 97.25 3561.25 36.62
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 21.00 1165.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 20 41.50 2603.00 62.72
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Total 138.75 6164.25 44.43
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Number of Children (Unduplicated) With at Least One Service 36
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Center 52
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 147 126.50 5659.00 0.00
P 19 8.25 305.25 305.25
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
4 4.00 200.00 0.00
Other 0 0.00 0.00 0.00
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Total 170 138.75 6164.25 305.25