CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:TPIN
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 3 4.25 157.25 37.00
Subtotal (Total Children Is Unduplicated) 3 4.25 157.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 62.50 4687.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 58.50 3246.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 20.50 1537.50 75.00
Subtotal (Total Children Is Unduplicated) 56 155.00 10484.25 67.64
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 1 2.00 100.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 161.25 10741.50 66.61
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 57
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 36 43.50 2589.75 0.00
S 0 0.00 0.00 0.00
H 3 6.00 400.00 0.00
T 0 0.00 0.00 0.00
4 4.25 157.25 0.00
Other 80 107.50 7594.50 0.00
-------------------------------------------------
Total 123 161.25 10741.50 0.00