CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 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 79 363.25 13329.25 36.69
Subtotal (Total Children Is Unduplicated) 79 363.25 13329.25 36.69
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 34.50 2587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 18.50 1387.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 58.50 3246.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 64 137.00 8616.25 62.89
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Total 500.25 21945.50 43.87
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Number of Children (Unduplicated) With at Least One Service 79
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Center 52
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 334 244.50 10247.50 0.00
P 285 216.50 9448.75 9442.75
D 0 0.00 0.00 0.00
S 1 3.25 120.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
31 36.00 2129.00 0.00
Other 0 0.00 0.00 0.00
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Total 651 500.25 21945.50 9442.75