CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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 14.25 527.25 37.00
Subtotal (Total Children Is Unduplicated) 3 14.25 527.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 -4.00 -300.00 0.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.50 562.50 75.00
Subtotal (Total Children Is Unduplicated) 6 7.50 484.50 64.60
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 -5.00 -131.46 0.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 117.00 58.50 0.50
Subtotal (Total Children Is Unduplicated) 2 112.00 -72.96 -0.65
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Total 133.75 938.79 7.02
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Number of Children (Unduplicated) With at Least One Service 10
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Center 07
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 2 -4.00 -300.00 -300.00
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
25 137.25 1220.29 0.00
Other 0 0.00 0.00 0.00
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Total 28 133.75 938.79 -300.00