CMS/EIP Fiscal Report Center: 10
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 147 490.25 18139.25 37.00
Subtotal (Total Children Is Unduplicated) 147 490.25 18139.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 60.50 4537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 34.50 2587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 45.00 3375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 94.00 5217.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 38.50 2887.50 75.00
Subtotal (Total Children Is Unduplicated) 72 277.50 18950.25 68.29
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Total 767.75 37089.50 48.31
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Number of Children (Unduplicated) With at Least One Service 147
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Center 10
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 500 461.75 20012.75 0.00
P 169 239.50 14616.25 14616.25
D 0 0.00 0.00 0.00
S 66 66.25 2451.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 736 767.75 37089.50 14616.25