CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 330 738.50 27047.00 36.62
Subtotal (Total Children Is Unduplicated) 330 738.50 27047.00 36.62
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 1 2.00 111.00 55.50
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Total 740.50 27158.00 36.68
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Number of Children (Unduplicated) With at Least One Service 330
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Center 02
Flag Claims Units Chgs Paid
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R 83 55.75 2025.75 0.00
U 0 0.00 0.00 0.00
B 761 640.75 23467.25 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
25 44.00 1665.00 0.00
Other 0 0.00 0.00 0.00
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Total 869 740.50 27158.00 0.00