CMS/EIP Fiscal Report Center: 10
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 111 469.75 17380.75 37.00
Subtotal (Total Children Is Unduplicated) 111 469.75 17380.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 62.00 4650.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 39.00 2925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 33.50 2512.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 89.50 4967.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 37.50 2812.50 75.00
Subtotal (Total Children Is Unduplicated) 70 267.00 18279.75 68.46
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Total 736.75 35660.50 48.40
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Number of Children (Unduplicated) With at Least One Service 111
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Center 10
Flag Claims Units Chgs Paid
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R 8 3.75 138.75 0.00
U 0 0.00 0.00 0.00
B 404 372.75 14842.50 74.00
P 250 319.25 18764.50 18764.50
D 0 0.00 0.00 0.00
S 39 41.00 1914.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 701 736.75 35660.50 18838.50