CMS/EIP Fiscal Report Center: 53
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 59.50 2201.50 37.00
Subtotal (Total Children Is Unduplicated) 19 59.50 2201.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 20.50 1537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 41.50 2303.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.50 2062.50 75.00
Subtotal (Total Children Is Unduplicated) 25 99.50 6653.25 66.87
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Total 159.00 8854.75 55.69
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Number of Children (Unduplicated) With at Least One Service 25
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Center 53
Flag Claims Units Chgs Paid
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R 6 12.00 707.00 0.00
U 0 0.00 0.00 0.00
B 37 50.50 2388.25 0.00
P 52 87.00 5180.00 5180.00
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
7 9.50 579.50 0.00
Other 0 0.00 0.00 0.00
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Total 102 159.00 8854.75 5180.00