CMS/EIP Fiscal Report Center: 51
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 7 36.00 1332.00 37.00
Subtotal (Total Children Is Unduplicated) 7 36.00 1332.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
Subtotal (Total Children Is Unduplicated) 3 6.00 450.00 75.00
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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 1 9.00 610.92 67.88
Subtotal (Total Children Is Unduplicated) 2 10.00 660.92 66.09
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Total 52.00 2442.92 46.98
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Number of Children (Unduplicated) With at Least One Service 7
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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 47 40.00 1632.00 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
8 12.00 810.92 0.00
Other 0 0.00 0.00 0.00
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Total 55 52.00 2442.92 0.00