CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:OTHER
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
CASE-CASE-NON-TCM CASE MANAGEMENT 10 4.25 157.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 1.75 64.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 317 785.75 29054.25 36.98
Subtotal (Total Children Is Unduplicated) 319 791.75 29276.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.00 1725.00 75.00
Subtotal (Total Children Is Unduplicated) 16 30.50 2287.50 75.00
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Total 822.25 31563.75 38.39
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Number of Children (Unduplicated) With at Least One Service 334
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Center 09
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 0 0.00 0.00 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
950 822.25 31563.75 0.00
Other 0 0.00 0.00 0.00
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Total 950 822.25 31563.75 0.00