CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 47 79.25 2932.25 37.00
Subtotal (Total Children Is Unduplicated) 47 80.00 2960.00 37.00
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.00 825.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 64.50 4837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 58.50 4387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 69 157.00 11661.00 74.27
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 7.00 475.16 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 8.50 576.98 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.50 576.98 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 6 57.00 1794.12 31.48
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Total 294.00 16415.12 55.83
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Number of Children (Unduplicated) With at Least One Service 111
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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
237 294.00 16415.12 0.00
Other 0 0.00 0.00 0.00
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Total 237 294.00 16415.12 0.00