CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 Page: 1
Payclass Filters:GR
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
CASE-CASE-NON-TCM CASE MANAGEMENT 59 23.75 878.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 10.25 379.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 87 212.50 7862.50 37.00
Subtotal (Total Children Is Unduplicated) 121 246.50 9120.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 28.50 2137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 26.00 1950.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 71.50 3968.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 15 16.00 800.00 50.00
Subtotal (Total Children Is Unduplicated) 60 153.00 9593.00 62.70
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Total 399.50 18713.50 46.84
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Number of Children (Unduplicated) With at Least One Service 132
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Center 03
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 1 2.00 150.00 150.00
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 309 256.25 11696.25 11696.25
134 141.25 6867.25 0.00
Other 0 0.00 0.00 0.00
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Total 444 399.50 18713.50 11846.25