CMS/EIP Fiscal Report Center: 53
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 22 67.00 2479.00 37.00
Subtotal (Total Children Is Unduplicated) 22 67.00 2479.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.00 600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.50 1415.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.50 712.50 75.00
Subtotal (Total Children Is Unduplicated) 14 53.00 3477.75 65.62
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
Subtotal (Total Children Is Unduplicated) 1 1.00 25.00 25.00
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Total 121.00 5981.75 49.44
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Number of Children (Unduplicated) With at Least One Service 23
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Center 53
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 31 35.00 1295.00 0.00
P 51 78.00 4086.75 4086.75
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
4 8.00 600.00 0.00
Other 0 0.00 0.00 0.00
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Total 86 121.00 5981.75 4086.75