CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 337 916.75 33901.25 36.98
Subtotal (Total Children Is Unduplicated) 337 916.75 33901.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 24.00 1800.00 75.00
Subtotal (Total Children Is Unduplicated) 17 25.50 1912.50 75.00
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Total 942.25 35813.75 38.01
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Number of Children (Unduplicated) With at Least One Service 337
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Center 55
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 129 154.75 6181.75 0.00
P 745 738.75 27828.25 27828.25
D 0 0.00 0.00 0.00
S 11 12.75 471.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
33 36.00 1332.00 0.00
Other 0 0.00 0.00 0.00
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Total 918 942.25 35813.75 27828.25