CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
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 272 604.00 22088.50 36.57
Subtotal (Total Children Is Unduplicated) 272 604.00 22088.50 36.57
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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 12 24.00 1800.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.00 1050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 27.00 1498.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.00 1050.00 75.00
Subtotal (Total Children Is Unduplicated) 28 94.00 6484.50 68.98
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Total 698.00 28573.00 40.94
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Number of Children (Unduplicated) With at Least One Service 274
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Center 02
Flag Claims Units Chgs Paid
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R 17 13.50 499.50 0.00
U 0 0.00 0.00 0.00
B 649 536.50 19637.25 0.00
P 1 0.50 18.50 0.00
D 0 0.00 0.00 0.00
S 1 1.25 46.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
95 146.25 8371.50 0.00
Other 0 0.00 0.00 0.00
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Total 763 698.00 28573.00 0.00