CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2008 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 76 415.25 15308.75 36.87
Subtotal (Total Children Is Unduplicated) 76 415.25 15308.75 36.87
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.50 900.00 72.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 34.00 1887.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 27 74.50 4887.00 65.60
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Total 489.75 20195.75 41.24
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Number of Children (Unduplicated) With at Least One Service 76
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Center 02
Flag Claims Units Chgs Paid
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R 6 6.75 249.75 0.00
U 0 0.00 0.00 0.00
B 362 343.25 12700.25 0.00
P 0 0.00 0.00 0.00
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
94 139.75 7245.75 0.00
Other 0 0.00 0.00 0.00
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Total 462 489.75 20195.75 0.00