CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 54 145.25 5374.25 37.00
Subtotal (Total Children Is Unduplicated) 54 145.25 5374.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 3.00 166.50 55.50
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
Subtotal (Total Children Is Unduplicated) 5 8.00 1091.50 136.44
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 23.00 1150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 4 24.00 1217.88 50.75
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Total 177.25 7683.63 43.35
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Number of Children (Unduplicated) With at Least One Service 54
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 77 65.75 2488.25 0.00
P 118 82.50 3348.50 3079.76
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 8 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
6 4.25 601.25 0.00
Other 0 0.00 0.00 0.00
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Total 210 177.25 7683.63 4297.64