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:Program Patients
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 358 894.25 32920.75 36.81
Subtotal (Total Children Is Unduplicated) 358 894.25 32920.75 36.81
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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 26 48.00 3600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 33.00 2475.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 47.50 2636.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.00 1575.00 75.00
Subtotal (Total Children Is Unduplicated) 53 166.50 11512.50 69.14
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Total 1060.75 44433.25 41.89
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Number of Children (Unduplicated) With at Least One Service 359
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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 1045 865.50 31857.00 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
116 184.75 12187.75 0.00
Other 0 0.00 0.00 0.00
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Total 1174 1060.75 44433.25 0.00