CMS/EIP Fiscal Report Center: 55
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 90 550.75 20359.25 36.97
Subtotal (Total Children Is Unduplicated) 90 550.75 20359.25 36.97
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 93.00 6975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 48.50 3637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.00 1125.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 45.50 2525.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 33.00 2475.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 72 240.00 17086.25 71.19
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Total 790.75 37445.50 47.35
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Number of Children (Unduplicated) With at Least One Service 94
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Center 55
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 12 15.00 1049.00 0.00
P 499 554.25 21191.75 21191.75
D 0 0.00 0.00 0.00
S 10 13.50 556.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
107 207.00 14611.25 0.00
Other 1 0.50 18.50 0.00
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Total 630 790.75 37445.50 21191.75