CMS/EIP Fiscal Report Center: 52
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 29 101.00 3709.25 36.73
Subtotal (Total Children Is Unduplicated) 29 101.00 3709.25 36.73
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 16.50 1184.50 71.79
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.50 461.00 70.92
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 17.50 971.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 17 41.50 2666.75 64.26
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Total 142.50 6376.00 44.74
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Number of Children (Unduplicated) With at Least One Service 29
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Center 52
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 151 127.00 5385.25 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
14 15.50 990.75 0.00
Other 0 0.00 0.00 0.00
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Total 165 142.50 6376.00 0.00