CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 673 3686.50 136291.50 36.97
Subtotal (Total Children Is Unduplicated) 673 3686.50 136291.50 36.97
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.50 1082.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 141.00 10537.50 74.73
Subtotal (Total Children Is Unduplicated) 112 173.50 12655.75 72.94
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Total 3860.00 148947.25 38.59
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Number of Children (Unduplicated) With at Least One Service 673
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Center 55
Flag Claims Units Chgs Paid
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R 38 47.00 1739.00 0.00
U 0 0.00 0.00 0.00
B 75 106.50 7227.00 0.00
P 3679 3665.75 138145.50 138145.00
D 0 0.00 0.00 0.00
S 26 27.75 1083.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 13.00 752.00 0.00
Other 0 0.00 0.00 0.00
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Total 3826 3860.00 148947.25 138145.00