CMS/EIP Fiscal Report Center: 05
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 23 115.00 4255.00 37.00
Subtotal (Total Children Is Unduplicated) 23 115.00 4255.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
Subtotal (Total Children Is Unduplicated) 8 13.00 828.75 63.75
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Total 128.00 5083.75 39.72
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Number of Children (Unduplicated) With at Least One Service 23
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Center 05
Flag Claims Units Chgs Paid
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R 20 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 123 95.50 3533.50 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
17 19.25 1060.00 0.00
Other 0 0.00 0.00 0.00
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Total 160 128.00 5083.75 0.00