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: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 59 203.75 7538.75 37.00
Subtotal (Total Children Is Unduplicated) 59 203.75 7538.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 28.50 2137.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 24.00 1800.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 39.50 2192.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 43 103.50 6788.00 65.58
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Total 307.25 14326.75 46.63
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Number of Children (Unduplicated) With at Least One Service 59
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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 6 1.50 55.50 0.00
P 341 284.25 12863.00 12863.00
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
19 21.50 1408.25 0.00
Other 0 0.00 0.00 0.00
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Total 366 307.25 14326.75 12863.00