CMS/EIP Fiscal Report Center: 52
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 27 97.75 3598.25 36.81
Subtotal (Total Children Is Unduplicated) 27 97.75 3598.25 36.81
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 19.50 1082.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 16 40.00 2594.75 64.87
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Total 137.75 6193.00 44.96
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Number of Children (Unduplicated) With at Least One Service 27
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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 91 66.25 2517.50 0.00
P 68 55.00 2541.00 2541.00
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
12 16.50 1134.50 0.00
Other 0 0.00 0.00 0.00
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Total 171 137.75 6193.00 2541.00