CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 60 161.00 5957.00 37.00
Subtotal (Total Children Is Unduplicated) 60 161.00 5957.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 4 5.00 309.50 61.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 21.00 1050.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 2 22.00 1117.88 50.81
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Total 188.00 7384.38 39.28
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Number of Children (Unduplicated) With at Least One Service 60
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Center 04
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 90 62.25 2416.25 0.00
P 124 102.75 3801.75 3801.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 7 23.00 1166.38 1166.38
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 221 188.00 7384.38 4968.13