CMS/EIP Fiscal Report Center: 55
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 3.00 101.75 33.92
Subtotal (Total Children Is Unduplicated) 3 3.25 111.00 34.15
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.50 262.50 58.33
EXIT-EXIT-TRANSITION ASSESSMENT 7 14.00 900.00 64.29
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 48.40 3629.82 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 30.00 2250.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.33 324.81 75.01
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.00 582.75 48.56
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.50 1162.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 4.66 226.20 48.54
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.98 47.36 48.33
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 4.64 225.00 48.49
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 6.93 336.00 48.48
Subtotal (Total Children Is Unduplicated) 68 145.94 9946.94 68.16
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 6.00 300.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 12.50 625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 131.91 8886.52 67.37
OCCT-97530HM-OT SESSION BY OT ASST 2 3.75 203.70 54.32
PHY-97110-PT SESSION BY LICENSED PT 32 94.37 6396.13 67.78
PHY-97110HM-PT SESSION BY PT ASST 4 6.50 353.08 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 237.89 16149.94 67.89
Subtotal (Total Children Is Unduplicated) 118 496.92 33051.81 66.51
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Total 646.11 43109.75 66.72
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Number of Children (Unduplicated) With at Least One Service 157
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Center 55
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 7 6.00 428.64 428.64
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 19 15.50 828.64 828.64
858 624.61 41852.47 0.00
Other 0 0.00 0.00 0.00
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Total 884 646.11 43109.75 1257.28