CMS/EIP Fiscal Report Center: 09
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 107 220.00 8140.00 37.00
Subtotal (Total Children Is Unduplicated) 107 220.00 8140.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 48.00 3600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 46.50 3487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 75.50 4190.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 95 222.00 14832.75 66.81
----------------------------------------------------------------------------------------------------------------
Total 442.00 22972.75 51.97
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 121
----------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 29 38.75 2275.75 0.00
P 315 399.75 20491.50 20491.50
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
1 2.00 150.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 347 442.00 22972.75 20491.50