CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 5 28.00 1036.00 37.00
Subtotal (Total Children Is Unduplicated) 5 28.00 1036.00 37.00
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 1 1.00 48.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 11.00 746.68 67.88
Subtotal (Total Children Is Unduplicated) 2 14.00 896.68 64.05
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Total 43.00 1981.18 46.07
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Number of Children (Unduplicated) With at Least One Service 6
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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 36 28.00 1036.00 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
9 15.00 945.18 0.00
Other 0 0.00 0.00 0.00
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Total 45 43.00 1981.18 0.00