CMS/EIP Fiscal Report Center: 51
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 30 165.75 6132.75 37.00
Subtotal (Total Children Is Unduplicated) 30 165.75 6132.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 16.50 1237.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 17.00 1275.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 19 36.50 2711.00 74.27
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Total 202.25 8843.75 43.73
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Number of Children (Unduplicated) With at Least One Service 30
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Center 51
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 177 166.75 6207.75 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
33 35.50 2636.00 0.00
Other 0 0.00 0.00 0.00
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Total 210 202.25 8843.75 0.00