CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 6 8.00 400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 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 8 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.00 525.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 72.00 5325.00 73.96
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 25.50 1912.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 37.00 2775.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 10 10.00 782.37 78.24
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 7.00 376.13 53.73
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 18.00 899.50 49.97
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 17 17.00 824.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 27 28.00 1358.00 48.50
Subtotal (Total Children Is Unduplicated) 166 265.00 17224.50 65.00
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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 33.00 1650.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 115 814.25 55271.29 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 112 923.21 62644.09 67.85
PHY-97110HM-PT SESSION BY PT ASST 2 2.50 135.80 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 211 1543.75 104762.41 67.86
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 18.50 1004.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 10 43.50 574.20 13.20
Subtotal (Total Children Is Unduplicated) 291 3382.71 226255.67 66.89
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Total 3647.71 243480.17 66.75
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Number of Children (Unduplicated) With at Least One Service 345
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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
6750 3647.71 243480.17 0.00
Other 0 0.00 0.00 0.00
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Total 6750 3647.71 243480.17 0.00