CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
CASE-CASE-NON-TCM CASE MANAGEMENT 4 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 235 737.00 27249.75 36.97
Subtotal (Total Children Is Unduplicated) 235 743.00 27397.75 36.87
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.50 27.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 23.00 1725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.00 444.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 34 66.00 4784.25 72.49
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 178.00 8840.00 49.66
OCCT-97530-OT SESSION BY LICENSED OT 11 66.50 4514.02 67.88
PHY-97110-PT SESSION BY LICENSED PT 9 50.50 3414.38 67.61
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 327.50 22230.70 67.88
Subtotal (Total Children Is Unduplicated) 60 623.50 39049.10 62.63
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Total 1432.50 71231.10 49.73
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Number of Children (Unduplicated) With at Least One Service 319
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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 137 507.75 31330.71 31330.71
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
1002 924.75 39900.39 0.00
Other 0 0.00 0.00 0.00
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Total 1139 1432.50 71231.10 31330.71