CMS/EIP Fiscal Report Center: 57
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 424 944.00 34928.00 37.00
Subtotal (Total Children Is Unduplicated) 424 944.00 34928.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 62.50 4687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 78.50 4356.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 56 149.00 9595.50 64.40
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Total 1093.00 44523.50 40.74
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Number of Children (Unduplicated) With at Least One Service 440
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Center 57
Flag Claims Units Chgs Paid
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R 181 179.50 6726.25 0.00
U 0 0.00 0.00 0.00
B 875 905.00 37341.50 0.00
P 1 2.00 74.00 74.00
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
7 6.50 381.75 0.00
Other 0 0.00 0.00 0.00
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Total 1064 1093.00 44523.50 74.00