CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 5.00 185.00 37.00
Subtotal (Total Children Is Unduplicated) 3 5.25 194.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 1 2.00 150.00 75.00
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Total 7.25 344.25 47.48
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Number of Children (Unduplicated) With at Least One Service 3
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Center 03
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 0 0.00 0.00 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 11 7.25 344.25 344.25
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 11 7.25 344.25 344.25