CMS/EIP Fiscal Report Center: 54
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 75 286.75 10582.00 36.90
Subtotal (Total Children Is Unduplicated) 75 286.75 10582.00 36.90
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 7.00 525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 20.00 1500.00 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 13 16.50 1237.50 75.00
Subtotal (Total Children Is Unduplicated) 37 69.50 4783.50 68.83
----------------------------------------------------------------------------------------------------------------
Total 356.25 15365.50 43.13
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 77
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 116 103.75 5438.00 0.00
P 310 243.25 9300.25 9300.25
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
11 9.25 627.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 437 356.25 15365.50 9300.25