CMS/EIP Fiscal Report Center: 57
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 26 135.75 5022.75 37.00
Subtotal (Total Children Is Unduplicated) 26 135.75 5022.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 16.50 915.75 55.50
Subtotal (Total Children Is Unduplicated) 13 32.00 2078.25 64.95
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Total 167.75 7101.00 42.33
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Number of Children (Unduplicated) With at Least One Service 28
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Center 57
Flag Claims Units Chgs Paid
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R 9 11.75 434.75 0.00
U 0 0.00 0.00 0.00
B 77 110.25 4597.50 0.00
P 34 45.75 2068.75 2068.75
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 120 167.75 7101.00 2068.75