CMS/EIP Fiscal Report Center: 57
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 11 43.75 1618.75 37.00
Subtotal (Total Children Is Unduplicated) 11 43.75 1618.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.00 499.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 6 17.00 1099.50 64.68
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Total 60.75 2718.25 44.74
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Number of Children (Unduplicated) With at Least One Service 12
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Center 57
Flag Claims Units Chgs Paid
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R 5 3.75 138.75 0.00
U 0 0.00 0.00 0.00
B 35 57.00 2579.50 0.00
P 0 0.00 0.00 0.00
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 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 40 60.75 2718.25 0.00