CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 3 8.75 323.75 37.00
Subtotal (Total Children Is Unduplicated) 3 8.75 323.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 2 3.50 223.50 63.86
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Total 12.25 547.25 44.67
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Number of Children (Unduplicated) With at Least One Service 3
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Center 52
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 0 0.00 0.00 0.00
P 13 12.25 547.25 547.25
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 13 12.25 547.25 547.25