CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2008 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 338 839.50 30996.75 36.92
Subtotal (Total Children Is Unduplicated) 338 839.50 30996.75 36.92
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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 2 3.00 225.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 38.50 2887.50 75.00
Subtotal (Total Children Is Unduplicated) 29 43.50 3362.50 77.30
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Total 883.00 34359.25 38.91
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Number of Children (Unduplicated) With at Least One Service 338
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Center 55
Flag Claims Units Chgs Paid
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R 30 38.25 1415.25 0.00
U 0 0.00 0.00 0.00
B 11 15.00 1068.00 0.00
P 856 815.50 31115.75 31115.75
D 0 0.00 0.00 0.00
S 6 7.25 268.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5 7.00 492.00 0.00
Other 0 0.00 0.00 0.00
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Total 908 883.00 34359.25 31115.75