CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 19 19.50 1951.75 100.09
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 61.00 3050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 24 112.60 7643.29 67.88
PHY-97110-PT SESSION BY LICENSED PT 12 61.00 4140.68 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 5.50 298.76 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 93.50 6346.78 67.88
Subtotal (Total Children Is Unduplicated) 57 333.60 21479.51 64.39
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Total 353.10 23431.26 66.36
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Number of Children (Unduplicated) With at Least One Service 66
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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 30 75.50 4905.29 6237.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 115 277.60 18525.97 18227.56
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 145 353.10 23431.26 24464.95