CMS/EIP Fiscal Report Center: 09
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 141 343.75 12718.75 37.00
Subtotal (Total Children Is Unduplicated) 141 343.75 12718.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.00 600.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 103 137.00 10275.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.00 2325.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 33.50 2512.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 150.50 8352.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 134 389.00 26113.50 67.13
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Total 732.75 38832.25 53.00
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Number of Children (Unduplicated) With at Least One Service 164
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Center 09
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 497 670.75 34970.75 0.00
P 33 38.50 2731.50 2731.50
D 0 0.00 0.00 0.00
S 2 3.00 195.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
11 20.50 934.25 0.00
Other 0 0.00 0.00 0.00
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Total 543 732.75 38832.25 2731.50