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: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 117 457.50 16927.50 37.00
Subtotal (Total Children Is Unduplicated) 117 457.50 16927.50 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 26.00 1950.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 28.50 1581.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 42 75.00 5069.25 67.59
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Total 532.50 21996.75 41.31
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Number of Children (Unduplicated) With at Least One Service 119
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Center 01
Flag Claims Units Chgs Paid
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R 19 22.75 1424.25 0.00
U 0 0.00 0.00 0.00
B 200 170.25 6582.25 0.00
P 113 98.50 3879.75 3879.75
D 20 22.00 1611.00 0.00
S 194 179.00 6623.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
35 32.00 1276.50 0.00
Other 6 8.00 600.00 0.00
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Total 587 532.50 21996.75 3879.75