CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
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 269 614.50 22560.75 36.71
Subtotal (Total Children Is Unduplicated) 269 614.50 22560.75 36.71
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 60.00 4500.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 14.50 1087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 29.00 1609.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 38.00 2850.00 75.00
Subtotal (Total Children Is Unduplicated) 49 155.00 11059.50 71.35
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Total 769.50 33620.25 43.69
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Number of Children (Unduplicated) With at Least One Service 277
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Center 02
Flag Claims Units Chgs Paid
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R 3 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 722 571.50 21034.50 0.00
P 0 0.00 0.00 0.00
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
148 196.50 12530.25 0.00
Other 1 0.75 27.75 0.00
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Total 874 769.50 33620.25 0.00