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:Program Patients
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 16 21.00 1050.00 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 72 86.50 6412.50 74.13
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 27.00 2025.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 41.00 3075.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 7.00 388.50 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 14 14.00 1091.68 77.98
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 11 16.00 865.10 54.07
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 13 13.00 630.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1552.00 48.50
Subtotal (Total Children Is Unduplicated) 192 321.00 20666.28 64.38
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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 212 1545.75 104898.17 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) 292 3384.71 226391.43 66.89
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Total 3705.71 247057.71 66.67
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Number of Children (Unduplicated) With at Least One Service 372
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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
6807 3705.71 247057.71 0.00
Other 0 0.00 0.00 0.00
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Total 6807 3705.71 247057.71 0.00