CMS/EIP Fiscal Report Center: 55
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 32 151.50 5587.00 36.88
Subtotal (Total Children Is Unduplicated) 32 151.50 5587.00 36.88
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
Subtotal (Total Children Is Unduplicated) 21 71.50 5128.50 71.73
----------------------------------------------------------------------------------------------------------------
Total 223.00 10715.50 48.05
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 10 12.50 519.50 0.00
P 108 122.75 4694.25 4694.25
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
52 87.75 5501.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 170 223.00 10715.50 4694.25