CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 1 6.75 249.75 37.00
Subtotal (Total Children Is Unduplicated) 1 6.75 249.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 1 2.00 130.50 65.25
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Total 8.75 380.25 43.46
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Number of Children (Unduplicated) With at Least One Service 1
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Center 57
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 0.25 9.25 0.00
P 4 6.25 231.25 231.25
D 0 0.00 0.00 0.00
S 1 0.25 9.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 2.00 130.50 0.00
Other 0 0.00 0.00 0.00
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Total 8 8.75 380.25 231.25