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: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 53 193.75 7168.75 37.00
Subtotal (Total Children Is Unduplicated) 53 193.75 7168.75 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 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 17 24.00 1800.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 10.50 761.00 72.48
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 28.50 1581.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 37 77.00 5037.00 65.42
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Total 270.75 12205.75 45.08
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Number of Children (Unduplicated) With at Least One Service 53
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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 303 258.75 11478.25 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 1 1.00 55.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
11 11.00 672.00 0.00
Other 0 0.00 0.00 0.00
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Total 315 270.75 12205.75 0.00