CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 12 12.00 1084.50 90.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 41.00 2050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 16 51.50 3495.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 11 28.98 1969.90 67.97
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 21.00 1425.48 67.88
Subtotal (Total Children Is Unduplicated) 34 142.48 8941.20 62.75
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Total 154.48 10025.70 64.90
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Number of Children (Unduplicated) With at Least One Service 41
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Center 04
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 18 48.50 2896.00 3540.62
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 47 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
2 1.50 93.00 0.00
Other 0 0.00 0.00 0.00
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Total 67 154.48 10025.70 10577.36