CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 48 137.25 5078.25 37.00
Subtotal (Total Children Is Unduplicated) 48 137.25 5078.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.00 750.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
Subtotal (Total Children Is Unduplicated) 7 18.50 1369.77 74.04
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 27.00 1350.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 11.00 746.68 67.88
Subtotal (Total Children Is Unduplicated) 5 38.00 2096.68 55.18
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Total 193.75 8544.70 44.10
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Number of Children (Unduplicated) With at Least One Service 49
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Center 06
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 100 74.25 2747.25 37.00
P 79 60.25 2343.25 2343.25
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
60 59.25 3454.20 0.00
Other 0 0.00 0.00 0.00
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Total 239 193.75 8544.70 2380.25