CMS/EIP Fiscal Report Center: 52
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 5 9.75 360.75 37.00
Subtotal (Total Children Is Unduplicated) 5 9.75 360.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 3 6.00 366.50 61.08
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Total 15.75 727.25 46.17
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Number of Children (Unduplicated) With at Least One Service 6
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Center 52
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 18 14.75 677.25 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
1 1.00 50.00 0.00
Other 0 0.00 0.00 0.00
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Total 19 15.75 727.25 0.00