CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 36.50 2662.50 72.95
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 123.50 61.75
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 50 74.50 5064.81 67.98
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 21.00 1050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 64 264.50 17954.26 67.88
PHY-97110-PT SESSION BY LICENSED PT 66 265.75 18039.11 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 2.00 108.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 104 440.25 29884.17 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 8.00 434.56 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 6.50 85.80 13.20
Subtotal (Total Children Is Unduplicated) 161 1009.00 67606.54 67.00
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Total 1083.50 72671.35 67.07
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Number of Children (Unduplicated) With at Least One Service 186
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Center 05
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
1995 1083.50 72671.35 0.00
Other 0 0.00 0.00 0.00
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Total 1995 1083.50 72671.35 0.00