CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 80 149.50 5531.50 37.00
Subtotal (Total Children Is Unduplicated) 80 149.50 5531.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 74.00 5550.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 16.00 1200.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 42.50 3187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 59.00 3274.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.00 900.00 75.00
Subtotal (Total Children Is Unduplicated) 87 215.50 14973.00 69.48
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Total 365.00 20504.50 56.18
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Number of Children (Unduplicated) With at Least One Service 111
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Center 09
Flag Claims Units Chgs Paid
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R 10 15.25 697.25 0.00
U 0 0.00 0.00 0.00
B 205 250.00 13791.50 0.00
P 67 81.00 5004.50 5004.50
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
14 18.75 1011.25 0.00
Other 0 0.00 0.00 0.00
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Total 296 365.00 20504.50 5004.50