CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1314 4025.75 148740.00 36.95
Subtotal (Total Children Is Unduplicated) 1314 4025.75 148740.00 36.95
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.50 637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 101.50 7612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.50 787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 95.50 5300.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 55.50 4162.50 75.00
Subtotal (Total Children Is Unduplicated) 87 292.50 19968.00 68.27
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 3 8.00 400.00 50.00
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Total 4326.25 169108.00 39.09
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Number of Children (Unduplicated) With at Least One Service 1314
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Center 01
Flag Claims Units Chgs Paid
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R 247 163.25 6227.50 0.00
U 0 0.00 0.00 0.00
B 3181 2269.25 85541.75 0.00
P 1 0.25 9.25 9.25
D 135 182.50 12085.50 0.00
S 2017 1494.00 55139.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
216 142.50 5443.50 0.00
Other 43 74.50 4661.25 0.00
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Total 5840 4326.25 169108.00 9.25