CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 86 379.50 14041.50 37.00
Subtotal (Total Children Is Unduplicated) 86 379.50 14041.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.50 1087.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 22.00 1221.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.00 900.00 75.00
Subtotal (Total Children Is Unduplicated) 28 59.50 4033.50 67.79
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Total 439.00 18075.00 41.17
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Number of Children (Unduplicated) With at Least One Service 87
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Center 01
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 270 267.00 9879.00 0.00
P 26 29.00 1073.00 1073.00
D 0 0.00 0.00 0.00
S 77 73.75 2728.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
17 21.25 1354.25 0.00
Other 43 48.00 3040.00 0.00
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Total 433 439.00 18075.00 1073.00