CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 61 146.25 5411.25 37.00
Subtotal (Total Children Is Unduplicated) 61 146.25 5411.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 10.00 750.00 75.00
Subtotal (Total Children Is Unduplicated) 8 21.00 1575.00 75.00
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.00 700.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 3.00 203.64 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 9.50 644.86 67.88
Subtotal (Total Children Is Unduplicated) 7 26.50 1548.50 58.43
----------------------------------------------------------------------------------------------------------------
Total 193.75 8534.75 44.05
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 61
----------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 137 98.25 3635.25 0.00
P 65 38.25 1415.25 1415.25
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
70 57.25 3484.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 272 193.75 8534.75 1415.25