CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 2 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 2 2.00 74.00 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 1 2.00 150.00 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2 5.00 309.50 61.90
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 300.00 150.00
PHY-97110-PT SESSION BY LICENSED PT 2 10.00 678.80 67.88
Subtotal (Total Children Is Unduplicated) 3 12.00 978.80 81.57
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Total 19.00 1362.30 71.70
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Number of Children (Unduplicated) With at Least One Service 7
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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
9 19.00 1362.30 0.00
Other 0 0.00 0.00 0.00
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Total 9 19.00 1362.30 0.00