CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 318 648.25 23920.50 36.90
Subtotal (Total Children Is Unduplicated) 318 648.25 23920.50 36.90
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 42.00 3112.50 74.11
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.00 1237.50 72.79
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 19.00 1387.50 73.03
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 52.50 2802.75 53.39
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 44 131.50 8615.25 65.52
----------------------------------------------------------------------------------------------------------------
Total 779.75 32535.75 41.73
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 321
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 777 571.50 21080.75 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
136 195.00 10964.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 929 779.75 32535.75 0.00