CMS/EIP Fiscal Report Center: 55
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 34 144.00 5328.00 37.00
Subtotal (Total Children Is Unduplicated) 34 144.00 5328.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.50 1612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.50 749.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.00 1050.00 75.00
Subtotal (Total Children Is Unduplicated) 22 67.50 4799.25 71.10
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Total 211.50 10127.25 47.88
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Number of Children (Unduplicated) With at Least One Service 34
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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 3 4.50 337.50 0.00
P 120 145.50 5744.50 5744.50
D 0 0.00 0.00 0.00
S 5 7.00 259.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
29 53.50 3749.25 0.00
Other 1 0.50 18.50 0.00
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Total 159 211.50 10127.25 5744.50