CMS/EIP Fiscal Report Center: 57
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 20 83.00 3071.00 37.00
Subtotal (Total Children Is Unduplicated) 20 83.00 3071.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 13.00 721.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 14 27.00 1771.50 65.61
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Total 110.00 4842.50 44.02
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Number of Children (Unduplicated) With at Least One Service 20
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Center 57
Flag Claims Units Chgs Paid
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R 10 16.50 610.50 0.00
U 0 0.00 0.00 0.00
B 25 32.75 1211.75 0.00
P 21 28.75 1063.75 1063.75
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
30 32.00 1956.50 0.00
Other 0 0.00 0.00 0.00
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Total 86 110.00 4842.50 1063.75