CMS/EIP Fiscal Report Center: 55
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 2 0.50 18.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 54 135.00 4865.50 36.04
Subtotal (Total Children Is Unduplicated) 55 137.50 4884.00 35.52
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
Subtotal (Total Children Is Unduplicated) 1 1.50 83.25 55.50
----------------------------------------------------------------------------------------------------------------
Total 139.00 4967.25 35.74
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 56
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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
134 139.00 4967.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 134 139.00 4967.25 0.00