CMS/EIP Fiscal Report Center: 51
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 1 0.50 18.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 75.00 50.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 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
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 70.00 70.00
Subtotal (Total Children Is Unduplicated) 10 12.50 683.00 54.64
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 211.48 70.49
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 26 86.50 5800.83 67.06
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 101.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 40 182.25 12405.07 68.07
PHY-97110HM-PT SESSION BY PT ASST 7 26.50 1439.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 221.50 15035.42 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 9.50 535.00 56.32
Subtotal (Total Children Is Unduplicated) 75 549.75 36331.90 66.09
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Total 562.75 37033.40 65.81
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Number of Children (Unduplicated) With at Least One Service 78
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Center 51
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 42 114.50 7264.49 7264.49
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
198 448.25 29768.91 0.00
Other 0 0.00 0.00 0.00
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Total 240 562.75 37033.40 7264.49