CMS/EIP Fiscal Report Center: 52
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.25 129.50 39.85
Subtotal (Total Children Is Unduplicated) 3 3.25 129.50 39.85
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 97.00 48.50
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 145.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 194.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 69.84 4531.18 64.88
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.00 339.50 42.44
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 10.50 617.50 58.81
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 61.35 3390.60 55.27
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.00 1082.50 83.27
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 4 4.00 200.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 13.00 582.00 44.77
Subtotal (Total Children Is Unduplicated) 120 209.69 12279.28 58.56
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.90 94.84 49.92
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 43 153.54 7734.44 50.37
OCCT-97530-OT SESSION BY LICENSED OT 40 230.61 15898.07 68.94
PHY-97110-PT SESSION BY LICENSED PT 46 177.00 12479.44 70.51
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 140 620.89 42535.05 68.51
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 188.00 94.00 0.50
Subtotal (Total Children Is Unduplicated) 212 1372.94 78890.16 57.46
----------------------------------------------------------------------------------------------------------------
Total 1585.88 91298.94 57.57
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 279
----------------------------------------------------------------------------------------------------------------
Center 52
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 21 31.09 3060.10 3060.10
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 95 173.75 10872.77 0.00
T 0 0.00 0.00 0.00
674 1381.04 77366.07 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 790 1585.88 91298.94 3060.10