CMS/EIP Fiscal Report Center: 07
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 52 178.25 6586.00 36.95
Subtotal (Total Children Is Unduplicated) 52 178.25 6586.00 36.95
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.50 971.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 46.50 3487.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 26 76.00 5133.75 67.55
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Total 254.25 11719.75 46.10
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Number of Children (Unduplicated) With at Least One Service 53
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Center 07
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 135 135.50 5949.25 0.00
P 87 93.75 4350.75 4350.75
D 1 0.50 18.50 0.00
S 9 10.50 536.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 14.00 864.75 0.00
Other 0 0.00 0.00 0.00
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Total 240 254.25 11719.75 4350.75