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: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 332 782.50 28813.75 36.82
Subtotal (Total Children Is Unduplicated) 332 782.50 28813.75 36.82
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 39.50 2962.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 26.00 1950.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 37.50 2081.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 42 136.00 9420.00 69.26
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Total 918.50 38233.75 41.63
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Number of Children (Unduplicated) With at Least One Service 333
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Center 02
Flag Claims Units Chgs Paid
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R 12 9.25 342.25 0.00
U 0 0.00 0.00 0.00
B 932 755.00 27796.25 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
98 154.25 10095.25 0.00
Other 0 0.00 0.00 0.00
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Total 1042 918.50 38233.75 0.00