CMS/EIP Fiscal Report Center: 07
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 54 166.00 6142.00 37.00
Subtotal (Total Children Is Unduplicated) 54 166.00 6142.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.00 1387.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 49.50 3712.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 27 88.50 6025.00 68.08
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.00 50.00 50.00
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Total 255.50 12217.00 47.82
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Number of Children (Unduplicated) With at Least One Service 54
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Center 07
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 42 32.25 1243.25 0.00
P 181 192.25 8966.25 8966.25
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
18 31.00 2007.50 0.00
Other 0 0.00 0.00 0.00
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Total 241 255.50 12217.00 8966.25