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: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 82 466.00 17242.00 37.00
Subtotal (Total Children Is Unduplicated) 82 466.00 17242.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 37.00 2775.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 22.50 1661.00 73.82
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 70.50 3912.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 14.50 1087.50 75.00
Subtotal (Total Children Is Unduplicated) 75 152.50 9938.75 65.17
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Total 618.50 27180.75 43.95
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Number of Children (Unduplicated) With at Least One Service 84
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Center 57
Flag Claims Units Chgs Paid
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R 22 28.50 1130.50 0.00
U 0 0.00 0.00 0.00
B 156 228.50 8454.50 0.00
P 148 208.50 7779.25 7779.20
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
144 153.00 9816.50 222.00
Other 0 0.00 0.00 0.00
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Total 470 618.50 27180.75 8001.20