CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 75 298.75 11053.75 37.00
Subtotal (Total Children Is Unduplicated) 75 298.75 11053.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 7.00 525.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.50 712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 16.50 915.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
Subtotal (Total Children Is Unduplicated) 26 43.50 2872.50 66.03
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Total 342.25 13926.25 40.69
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Number of Children (Unduplicated) With at Least One Service 76
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Center 01
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 82 94.75 3505.75 0.00
P 0 0.00 0.00 0.00
D 27 28.75 1063.75 0.00
S 36 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 22.00 1383.00 0.00
Other 143 154.00 6392.00 0.00
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Total 306 342.25 13926.25 0.00