CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 7.50 277.50 37.00
Subtotal (Total Children Is Unduplicated) 3 7.50 277.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 70.00 4671.50 66.74
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.00 322.00 64.40
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 21.61 1287.00 59.56
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 77.50 4301.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 22.00 1650.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 117 237.11 14227.75 60.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 220.95 11047.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 36 225.34 15296.32 67.88
PHY-97110-PT SESSION BY LICENSED PT 48 176.89 12047.46 68.11
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 124 523.28 35520.63 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 40.00 20.00 0.50
Subtotal (Total Children Is Unduplicated) 197 1187.96 74006.91 62.30
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Total 1432.57 88512.16 61.79
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Number of Children (Unduplicated) With at Least One Service 258
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Center 52
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 2.00 135.76 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 79 124.25 7962.08 0.00
T 0 0.00 0.00 0.00
677 1306.32 80414.32 0.00
Other 0 0.00 0.00 0.00
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Total 757 1432.57 88512.16 0.00