CMS/EIP Fiscal Report Center: 02
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 20 67.25 2488.25 37.00
Subtotal (Total Children Is Unduplicated) 20 67.25 2488.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 412.50 68.75
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.50 527.25 55.50
Subtotal (Total Children Is Unduplicated) 7 22.50 1464.75 65.10
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Total 89.75 3953.00 44.04
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Number of Children (Unduplicated) With at Least One Service 20
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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 50 47.75 1766.75 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
20 35.25 1936.50 0.00
Other 0 0.00 0.00 0.00
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Total 76 89.75 3953.00 0.00