CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:Program Patients
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 331 731.00 26732.50 36.57
Subtotal (Total Children Is Unduplicated) 331 731.00 26732.50 36.57
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 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 15 28.00 2100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 21.50 1612.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 47.50 2636.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 32 114.50 7622.25 66.57
----------------------------------------------------------------------------------------------------------------
Total 845.50 34354.75 40.63
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 331
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 12.50 462.50 0.00
U 0 0.00 0.00 0.00
B 811 668.25 24540.25 0.00
P 2 1.00 37.00 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
98 163.75 9315.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 929 845.50 34354.75 0.00