CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
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 1132 2775.75 102517.75 36.93
Subtotal (Total Children Is Unduplicated) 1132 2775.75 102517.75 36.93
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 51.00 2830.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 26.00 1950.00 75.00
Subtotal (Total Children Is Unduplicated) 45 86.00 5348.25 62.19
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 203.50 10175.00 50.00
Subtotal (Total Children Is Unduplicated) 62 203.50 10175.00 50.00
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Total 3065.25 118041.00 38.51
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Number of Children (Unduplicated) With at Least One Service 1168
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Center 01
Flag Claims Units Chgs Paid
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R 270 181.50 7041.50 0.00
U 0 0.00 0.00 0.00
B 3664 2688.50 101272.75 0.00
P 154 195.25 9726.75 9634.25
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 4088 3065.25 118041.00 9634.25