CMS/EIP Fiscal Report Center: 54
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 83 278.50 10202.75 36.63
Subtotal (Total Children Is Unduplicated) 83 278.50 10202.75 36.63
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 19.00 1425.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 14.00 1050.00 75.00
Subtotal (Total Children Is Unduplicated) 34 55.50 3928.50 70.78
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Total 334.00 14131.25 42.31
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Number of Children (Unduplicated) With at Least One Service 85
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Center 54
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 165 120.00 4562.75 0.00
P 251 163.00 6108.50 6108.50
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
44 51.00 3460.00 0.00
Other 0 0.00 0.00 0.00
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Total 460 334.00 14131.25 6108.50