CMS/EIP Fiscal Report Center: 05
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
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 8.00 400.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 19.00 1425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 16.50 1237.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 3.00 150.45 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 48 76.50 5076.41 66.36
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 159.50 10826.86 67.88
PHY-97110-PT SESSION BY LICENSED PT 64 207.25 14068.13 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 107 351.25 23842.85 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 1.50 81.48 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.75 36.30 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 139.00 69.50 0.50
Subtotal (Total Children Is Unduplicated) 158 872.50 49487.62 56.72
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Total 949.00 54564.03 57.50
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Number of Children (Unduplicated) With at Least One Service 181
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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 11 145.25 382.00 382.00
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
1445 803.75 54182.03 0.00
Other 0 0.00 0.00 0.00
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Total 1456 949.00 54564.03 382.00