CMS/EIP Fiscal Report Center: 10
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 5 8.75 323.75 37.00
Subtotal (Total Children Is Unduplicated) 5 8.75 323.75 37.00
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 10.50 712.74 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 2 16.00 1086.08 67.88
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Total 24.75 1409.83 56.96
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Number of Children (Unduplicated) With at Least One Service 5
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Center 10
Flag Claims Units Chgs Paid
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R 3 2.00 74.00 0.00
U 0 0.00 0.00 0.00
B 8 5.00 185.00 0.00
P 3 0.75 27.75 27.75
D 0 0.00 0.00 0.00
S 3 1.00 37.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 16.00 1086.08 0.00
Other 0 0.00 0.00 0.00
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Total 25 24.75 1409.83 27.75