CMS/EIP Fiscal Report Center: 51
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 7 19.75 730.75 37.00
Subtotal (Total Children Is Unduplicated) 7 19.75 730.75 37.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 6.50 441.22 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 203.64 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.00 339.40 67.88
Subtotal (Total Children Is Unduplicated) 4 20.50 1284.26 62.65
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Total 40.25 2015.01 50.06
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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 31 19.75 730.75 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
11 20.50 1284.26 0.00
Other 0 0.00 0.00 0.00
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Total 42 40.25 2015.01 0.00