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:Program Patients
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 290 675.00 24660.00 36.53
Subtotal (Total Children Is Unduplicated) 290 675.00 24660.00 36.53
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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 14 28.00 2100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 21.00 1575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.00 975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 34.50 1914.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 36 118.50 8175.75 68.99
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Total 793.50 32835.75 41.38
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Number of Children (Unduplicated) With at Least One Service 292
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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 716 603.00 22042.25 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
112 175.25 10229.25 0.00
Other 0 0.00 0.00 0.00
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Total 847 793.50 32835.75 0.00