CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 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 8 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 2 1.50 112.50 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 15 20.50 1537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 8.00 600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 15.00 1125.00 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 4 4.00 291.12 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.00 250.75 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 57 86.00 5628.87 65.45
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 164.75 11183.23 67.88
PHY-97110-PT SESSION BY LICENSED PT 61 197.25 13389.33 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 92 318.00 21585.84 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 11.00 597.52 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 142 703.00 47245.52 67.21
----------------------------------------------------------------------------------------------------------------
Total 789.00 52874.39 67.01
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 180
----------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
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
1427 789.00 52874.39 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1427 789.00 52874.39 0.00