CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 5 4.25 157.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 175 497.00 18389.00 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 177 503.75 18601.75 36.93
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.50 412.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 92.50 6937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 46.50 3487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.00 975.00 75.00
Subtotal (Total Children Is Unduplicated) 88 159.50 11962.50 75.00
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 39.00 2647.32 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 19.00 1289.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 19.50 1323.66 67.88
Subtotal (Total Children Is Unduplicated) 5 77.75 5273.20 67.82
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Total 741.00 35837.45 48.36
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Number of Children (Unduplicated) With at Least One Service 254
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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 1 5.00 339.40 339.40
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
718 736.00 35498.05 0.00
Other 0 0.00 0.00 0.00
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Total 719 741.00 35837.45 339.40