CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 108 278.25 10295.25 37.00
Subtotal (Total Children Is Unduplicated) 108 278.25 10295.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 15.00 832.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 20.50 1537.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 29 42.50 2829.50 66.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 40.00 2000.00 50.00
Subtotal (Total Children Is Unduplicated) 7 40.00 2000.00 50.00
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Total 360.75 15124.75 41.93
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Number of Children (Unduplicated) With at Least One Service 110
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Center 01
Flag Claims Units Chgs Paid
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R 20 18.00 1149.50 0.00
U 0 0.00 0.00 0.00
B 212 147.50 5971.25 0.00
P 136 94.25 3699.50 3699.50
D 3 3.00 225.00 0.00
S 78 58.75 2173.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 37.25 1805.75 0.00
Other 1 2.00 100.00 0.00
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Total 468 360.75 15124.75 3699.50