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:TPIN
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 1 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 4 8.00 600.00 75.00
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Total 10.00 674.00 67.40
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Number of Children (Unduplicated) With at Least One Service 5
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Center 02
Flag Claims Units Chgs Paid
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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 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
5 10.00 674.00 0.00
Other 0 0.00 0.00 0.00
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Total 5 10.00 674.00 0.00