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:MED
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 96 266.75 9869.75 37.00
Subtotal (Total Children Is Unduplicated) 96 266.75 9869.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 11 21.50 1203.62 55.98
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Total 288.25 11073.37 38.42
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Number of Children (Unduplicated) With at Least One Service 96
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Center 03
Flag Claims Units Chgs Paid
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R 4 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 9 9.75 360.75 0.00
P 280 256.25 9932.75 9935.75
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
15 15.25 564.25 0.00
Other 2 2.00 30.62 0.00
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Total 310 288.25 11073.37 9935.75