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:TPIN
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 9.50 351.50 37.00
Subtotal (Total Children Is Unduplicated) 3 11.50 425.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 18.50 1387.50 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 15 18.50 1026.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 16.50 1237.50 75.00
Subtotal (Total Children Is Unduplicated) 29 55.00 3764.25 68.44
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Total 66.50 4189.75 63.00
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Number of Children (Unduplicated) With at Least One Service 32
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Center 01
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 0 0.00 0.00 0.00
D 26 28.50 1952.25 0.00
S 8 10.25 379.25 0.00
H 9 10.00 652.50 0.00
T 0 0.00 0.00 0.00
2 2.25 121.25 0.00
Other 11 15.50 1084.50 0.00
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Total 56 66.50 4189.75 0.00