CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 9 5.00 185.00 37.00
Subtotal (Total Children Is Unduplicated) 9 5.00 185.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 2 8.00 561.00 70.13
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 10.00 678.80 67.88
Subtotal (Total Children Is Unduplicated) 1 10.00 678.80 67.88
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Total 23.00 1424.80 61.95
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Number of Children (Unduplicated) With at Least One Service 12
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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 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
18 23.00 1424.80 0.00
Other 0 0.00 0.00 0.00
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Total 18 23.00 1424.80 0.00