CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 1215 3548.75 131257.50 36.99
Subtotal (Total Children Is Unduplicated) 1215 3548.75 131257.50 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 66.50 4987.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 95.50 5300.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 83.50 6262.50 75.00
Subtotal (Total Children Is Unduplicated) 118 260.50 17548.50 67.36
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 27.75 1387.50 50.00
Subtotal (Total Children Is Unduplicated) 7 27.75 1387.50 50.00
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Total 3837.00 150193.50 39.14
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Number of Children (Unduplicated) With at Least One Service 1221
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Center 01
Flag Claims Units Chgs Paid
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R 70 82.50 5203.25 0.00
U 0 0.00 0.00 0.00
B 2036 1410.75 54400.75 0.00
P 1319 950.25 36181.00 36180.50
D 72 84.50 5937.50 0.00
S 1496 1146.25 42411.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
197 156.00 5810.00 0.00
Other 6 6.75 249.75 0.00
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Total 5196 3837.00 150193.50 36180.50