CMS/EIP Fiscal Report Center: 57
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 21 108.25 4005.25 37.00
Subtotal (Total Children Is Unduplicated) 21 108.25 4005.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.00 348.50 69.70
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 20.00 1110.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 22 43.00 2789.00 64.86
----------------------------------------------------------------------------------------------------------------
Total 151.25 6794.25 44.92
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 62 88.50 3274.50 0.00
P 17 19.75 730.75 730.75
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
43 43.00 2789.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 122 151.25 6794.25 730.75