CMS/EIP Fiscal Report Center: 52
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 33 131.00 4847.00 37.00
Subtotal (Total Children Is Unduplicated) 33 131.00 4847.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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 13 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 24 60.00 3976.50 66.28
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Total 191.00 8823.50 46.20
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Number of Children (Unduplicated) With at Least One Service 34
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Center 52
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 67 63.75 2838.50 0.00
P 101 83.50 3400.25 3400.25
D 0 0.00 0.00 0.00
S 15 10.00 370.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
24 33.75 2214.75 0.00
Other 0 0.00 0.00 0.00
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Total 207 191.00 8823.50 3400.25