CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 4 9.00 333.00 37.00
Subtotal (Total Children Is Unduplicated) 4 9.00 333.00 37.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 11.00 746.68 67.88
Subtotal (Total Children Is Unduplicated) 3 12.00 796.68 66.39
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Total 21.00 1129.68 53.79
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Number of Children (Unduplicated) With at Least One Service 5
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Center 51
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 14 9.00 333.00 0.00
P 0 0.00 0.00 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
5 12.00 796.68 0.00
Other 0 0.00 0.00 0.00
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Total 19 21.00 1129.68 0.00