CMS/EIP Fiscal Report Center: 02
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 31 93.75 3468.75 37.00
Subtotal (Total Children Is Unduplicated) 31 93.75 3468.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 22.00 1650.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.00 975.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 26.00 1443.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 20 71.00 4818.00 67.86
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Total 164.75 8286.75 50.30
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Number of Children (Unduplicated) With at Least One Service 32
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Center 02
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 97 82.75 3061.75 0.00
P 1 0.50 18.50 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
52 81.50 5206.50 0.00
Other 0 0.00 0.00 0.00
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Total 150 164.75 8286.75 0.00