CMS/EIP Fiscal Report Center: 05
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 324 1112.50 41162.50 37.00
Subtotal (Total Children Is Unduplicated) 324 1112.50 41162.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
Subtotal (Total Children Is Unduplicated) 3 4.50 337.50 75.00
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Total 1117.00 41500.00 37.15
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Number of Children (Unduplicated) With at Least One Service 324
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Center 05
Flag Claims Units Chgs Paid
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R 133 82.00 3034.00 0.00
U 0 0.00 0.00 0.00
B 1813 944.50 35117.50 0.00
P 0 0.00 0.00 0.00
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
141 90.50 3348.50 0.00
Other 0 0.00 0.00 0.00
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Total 2087 1117.00 41500.00 0.00