CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 58 145.75 5392.75 37.00
Subtotal (Total Children Is Unduplicated) 58 145.75 5392.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
Subtotal (Total Children Is Unduplicated) 3 8.00 570.75 71.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 2.50 169.70 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.50 576.98 67.88
Subtotal (Total Children Is Unduplicated) 7 20.00 1214.56 60.73
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Total 173.75 7178.06 41.31
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Number of Children (Unduplicated) With at Least One Service 58
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 15 9.50 351.50 0.00
P 248 135.00 4995.00 4995.00
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
36 28.75 1813.06 0.00
Other 0 0.00 0.00 0.00
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Total 300 173.75 7178.06 4995.00