CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 25 97.25 3570.50 36.71
Subtotal (Total Children Is Unduplicated) 25 97.25 3570.50 36.71
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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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.00 499.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 9 30.00 2074.50 69.15
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Total 127.25 5645.00 44.36
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Number of Children (Unduplicated) With at Least One Service 25
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Center 02
Flag Claims Units Chgs Paid
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R 2 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 83 82.25 3015.50 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
21 42.75 2546.25 0.00
Other 0 0.00 0.00 0.00
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Total 106 127.25 5645.00 0.00