CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 118.00 4366.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 46 120.00 4403.00 36.69
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.00 675.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 112.50 8437.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 59.50 4462.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 20.50 1537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
Subtotal (Total Children Is Unduplicated) 119 213.50 15895.50 74.45
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 10.50 712.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 5.00 339.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 4 19.50 1323.66 67.88
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Total 353.00 21622.16 61.25
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Number of Children (Unduplicated) With at Least One Service 166
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Center 09
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
292 353.00 21622.16 0.00
Other 0 0.00 0.00 0.00
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Total 292 353.00 21622.16 0.00