CMS/EIP Fiscal Report Center: 57
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 30 138.50 5124.50 37.00
Subtotal (Total Children Is Unduplicated) 30 138.50 5124.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 24.00 1800.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 34.50 1914.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
Subtotal (Total Children Is Unduplicated) 31 65.50 4220.25 64.43
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Total 204.00 9344.75 45.81
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Number of Children (Unduplicated) With at Least One Service 32
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Center 57
Flag Claims Units Chgs Paid
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R 17 25.00 1000.00 0.00
U 0 0.00 0.00 0.00
B 16 20.25 1109.25 0.00
P 96 127.25 5194.75 5194.75
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
30 31.50 2040.75 0.00
Other 0 0.00 0.00 0.00
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Total 159 204.00 9344.75 5194.75