CMS/EIP Fiscal Report Center: 09
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 108 204.25 7557.25 37.00
Subtotal (Total Children Is Unduplicated) 108 204.25 7557.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 71.50 5362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 49.00 3675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 49.00 2719.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 11.50 862.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 97 221.00 15361.00 69.51
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Total 425.25 22918.25 53.89
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Number of Children (Unduplicated) With at Least One Service 134
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Center 09
Flag Claims Units Chgs Paid
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R 2 4.00 185.00 0.00
U 0 0.00 0.00 0.00
B 86 109.00 5946.75 0.00
P 292 303.50 16275.25 16275.24
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
7 8.75 511.25 0.00
Other 0 0.00 0.00 0.00
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Total 387 425.25 22918.25 16275.24