CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 86 344.75 12718.75 36.89
Subtotal (Total Children Is Unduplicated) 86 344.75 12718.75 36.89
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.50 1312.50 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 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.50 1026.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.00 975.00 75.00
Subtotal (Total Children Is Unduplicated) 21 64.50 4437.75 68.80
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Total 409.25 17156.50 41.92
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Number of Children (Unduplicated) With at Least One Service 86
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Center 01
Flag Claims Units Chgs Paid
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R 10 11.00 545.75 0.00
U 0 0.00 0.00 0.00
B 230 205.00 7838.75 0.00
P 1 2.50 92.50 0.00
D 19 32.50 2351.25 0.00
S 161 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
14 13.00 557.00 0.00
Other 8 12.50 859.50 0.00
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Total 443 409.25 17156.50 0.00