CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.50 92.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 38 58.25 2155.25 37.00
Subtotal (Total Children Is Unduplicated) 38 60.75 2247.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 7.00 350.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 237.36 79.12
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 48.00 3577.99 74.54
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 109.69 73.13
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 58.50 3246.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 47.00 3525.00 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 78.11 78.11
Subtotal (Total Children Is Unduplicated) 76 178.50 12023.40 67.36
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.00 3712.91 530.42
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.50 125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 12.75 1617.88 126.89
OCCT-97530HM-OT SESSION BY OT ASST 1 0.25 23.94 95.76
PHY-97110-PT SESSION BY LICENSED PT 11 13.75 1468.89 106.83
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 84.50 8927.65 105.65
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 73.00 36.50 0.50
Subtotal (Total Children Is Unduplicated) 74 208.75 16662.77 79.82
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Total 448.00 30933.92 69.05
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Number of Children (Unduplicated) With at Least One Service 175
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Center 01
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 1 1.00 50.00 0.00
S 30 24.25 897.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
377 366.75 26079.17 0.00
Other 39 56.00 3907.50 0.00
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Total 447 448.00 30933.92 0.00