CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 196 694.00 25678.00 37.00
Subtotal (Total Children Is Unduplicated) 196 694.00 25678.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 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 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 75.50 5662.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 61.00 4575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 56.00 4200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 85 146.00 8103.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 48.00 3600.00 75.00
Subtotal (Total Children Is Unduplicated) 122 393.00 26589.00 67.66
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Total 1087.00 52267.00 48.08
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Number of Children (Unduplicated) With at Least One Service 198
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Center 10
Flag Claims Units Chgs Paid
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R 74 77.00 3747.75 0.00
U 0 0.00 0.00 0.00
B 789 721.25 30690.75 0.00
P 199 284.50 17671.25 17671.25
D 0 0.00 0.00 0.00
S 7 4.25 157.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 1069 1087.00 52267.00 17671.25