CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 366 965.75 35668.00 36.93
Subtotal (Total Children Is Unduplicated) 366 965.75 35668.00 36.93
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 51.00 3825.00 75.00
Subtotal (Total Children Is Unduplicated) 36 54.00 4050.00 75.00
----------------------------------------------------------------------------------------------------------------
Total 1019.75 39718.00 38.95
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 366
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 31 38.75 1433.75 0.00
U 0 0.00 0.00 0.00
B 15 20.00 1424.00 0.00
P 976 961.00 36860.25 36860.25
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1022 1019.75 39718.00 36860.25