CMS/EIP Fiscal Report Center: 52
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.00 547.00 68.38
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 61.50 4391.00 71.40
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.50 831.50 66.52
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 46.00 2525.25 54.90
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.50 862.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 11.00 535.40 48.67
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 86 179.00 11187.40 62.50
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.75 137.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 118.99 5913.46 49.70
OCCT-97530-OT SESSION BY LICENSED OT 34 152.77 10369.69 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 45 338.40 22993.63 67.95
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 598.27 40578.44 67.83
SPL-92508-GROUP SPL SESSION PER CHILD 4 17.00 224.40 13.20
Subtotal (Total Children Is Unduplicated) 189 1231.93 80417.58 65.28
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Total 1410.93 91604.98 64.93
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Number of Children (Unduplicated) With at Least One Service 243
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Center 52
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 1 0.89 60.41 60.41
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 58 92.50 5697.15 0.00
T 0 0.00 0.00 0.00
578 1317.54 85847.42 173.78
Other 0 0.00 0.00 0.00
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Total 637 1410.93 91604.98 234.19