CMS/EIP Fiscal Report Center: 02
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 26 111.75 4107.00 36.75
Subtotal (Total Children Is Unduplicated) 26 111.75 4107.00 36.75
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.00 525.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.00 555.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 11 30.50 2092.50 68.61
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Total 142.25 6199.50 43.58
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Number of Children (Unduplicated) With at Least One Service 26
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Center 02
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 113 110.50 4060.75 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 1 1.25 46.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 30.50 2092.50 0.00
Other 0 0.00 0.00 0.00
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Total 132 142.25 6199.50 0.00