CMS/EIP Fiscal Report Center: 54
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 6 16.75 619.75 37.00
Subtotal (Total Children Is Unduplicated) 6 16.75 619.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 2 2.00 111.00 55.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 11.00 550.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.50 169.70 67.88
Subtotal (Total Children Is Unduplicated) 2 13.50 719.70 53.31
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Total 32.25 1450.45 44.98
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Number of Children (Unduplicated) With at Least One Service 6
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Center 54
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 19 13.50 616.50 0.00
P 20 13.25 503.25 503.25
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
5 5.50 330.70 0.00
Other 0 0.00 0.00 0.00
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Total 44 32.25 1450.45 503.25