CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 88 234.00 8658.00 37.00
Subtotal (Total Children Is Unduplicated) 88 234.00 8658.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 29.50 1637.25 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 24 24.00 1200.00 50.00
Subtotal (Total Children Is Unduplicated) 41 82.50 4634.61 56.18
----------------------------------------------------------------------------------------------------------------
Total 316.50 13292.61 42.00
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 89
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 21 32.75 1211.75 0.00
P 259 262.50 11228.00 11178.00
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
14 14.50 733.25 0.00
Other 6 6.00 91.86 0.00
-------------------------------------------------
Total 301 316.50 13292.61 11178.00