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:Program Patients
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 295 699.75 25687.25 36.71
Subtotal (Total Children Is Unduplicated) 295 699.75 25687.25 36.71
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 73.00 5475.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 34.00 1887.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 44.00 3300.00 75.00
Subtotal (Total Children Is Unduplicated) 61 183.50 13099.50 71.39
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Total 883.25 38786.75 43.91
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Number of Children (Unduplicated) With at Least One Service 303
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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 816 652.50 24003.75 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
170 229.25 14727.50 0.00
Other 1 0.75 27.75 0.00
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Total 990 883.25 38786.75 0.00