CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 140 523.00 19323.25 36.95
Subtotal (Total Children Is Unduplicated) 140 523.00 19323.25 36.95
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 107.50 8062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 91.50 5077.75 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 46.00 3450.00 75.00
Subtotal (Total Children Is Unduplicated) 100 277.00 18951.25 68.42
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Total 800.00 38274.50 47.84
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Number of Children (Unduplicated) With at Least One Service 140
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Center 01
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 448 391.00 17331.75 0.00
P 208 163.00 6142.00 6142.00
D 1 0.50 18.50 0.00
S 129 120.75 5845.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 1.25 64.25 0.00
Other 87 123.50 8872.50 0.00
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Total 875 800.00 38274.50 6142.00