CMS/EIP Fiscal Report Center: 02
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 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
Subtotal (Total Children Is Unduplicated) 3 11.50 755.25 65.67
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Total 794.00 29569.00 37.24
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Number of Children (Unduplicated) With at Least One Service 332
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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
27 29.75 1430.50 0.00
Other 0 0.00 0.00 0.00
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Total 971 794.00 29569.00 0.00