CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
CASE-CASE-NON-TCM CASE MANAGEMENT 7 5.25 194.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 190 347.00 12839.00 37.00
Subtotal (Total Children Is Unduplicated) 192 353.25 13070.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 26.50 1987.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 16.50 1237.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 35 57.00 4063.50 71.29
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 4.50 305.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 5.50 373.34 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 1 13.00 882.44 67.88
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Total 423.25 18016.19 42.57
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Number of Children (Unduplicated) With at Least One Service 225
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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
493 423.25 18016.19 0.00
Other 0 0.00 0.00 0.00
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Total 493 423.25 18016.19 0.00