CMS/EIP Fiscal Report Center: 55
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 37 144.50 5318.75 36.81
Subtotal (Total Children Is Unduplicated) 37 144.50 5318.75 36.81
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.00 1725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.50 975.00 72.22
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 23.00 1248.75 54.29
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
Subtotal (Total Children Is Unduplicated) 23 77.00 5222.25 67.82
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Total 221.50 10541.00 47.59
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Number of Children (Unduplicated) With at Least One Service 38
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Center 55
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 0 0.00 0.00 0.00
P 126 139.00 5400.25 5400.25
D 0 0.00 0.00 0.00
S 5 5.00 185.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
46 77.50 4955.75 0.00
Other 0 0.00 0.00 0.00
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Total 177 221.50 10541.00 5400.25