CMS/EIP Fiscal Report Center: 55
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 23 85.00 3108.00 36.56
Subtotal (Total Children Is Unduplicated) 23 85.00 3108.00 36.56
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.00 675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
Subtotal (Total Children Is Unduplicated) 15 47.00 3261.75 69.40
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Total 132.00 6369.75 48.26
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Number of Children (Unduplicated) With at Least One Service 24
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Center 55
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 25 22.00 814.00 0.00
P 63 70.50 2856.50 2856.50
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
23 39.50 2699.25 0.00
Other 0 0.00 0.00 0.00
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Total 111 132.00 6369.75 2856.50