CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
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 7 7.25 268.25 37.00
Subtotal (Total Children Is Unduplicated) 7 7.25 268.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.50 562.50 75.00
Subtotal (Total Children Is Unduplicated) 10 34.00 2364.75 69.55
----------------------------------------------------------------------------------------------------------------
Total 41.25 2633.00 63.83
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 17
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 16 30.50 2102.25 0.00
S 0 0.00 0.00 0.00
H 2 3.50 262.50 0.00
T 0 0.00 0.00 0.00
11 7.25 268.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 29 41.25 2633.00 0.00