CMS/EIP Fiscal Report Center: 06
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 19 68.50 2534.50 37.00
Subtotal (Total Children Is Unduplicated) 19 68.50 2534.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.00 600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 8 16.00 1200.00 75.00
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Total 84.50 3734.50 44.20
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Number of Children (Unduplicated) With at Least One Service 19
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 23 18.50 684.50 0.00
P 49 40.25 1489.25 1489.25
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
27 25.75 1560.75 0.00
Other 0 0.00 0.00 0.00
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Total 99 84.50 3734.50 1489.25