CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.75 101.75 37.00
Subtotal (Total Children Is Unduplicated) 1 2.75 101.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 40.00 3000.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 27.50 2062.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 111.50 8362.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 94.50 7087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 23.00 1276.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 47.00 3525.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 3.00 145.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 152 386.50 27961.13 72.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 142 670.00 45479.60 67.88
PHY-97110-PT SESSION BY LICENSED PT 108 519.25 35246.69 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 24.00 1303.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 776.50 52708.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 25.00 12.50 0.50
Subtotal (Total Children Is Unduplicated) 286 2018.75 134951.29 66.85
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Total 2408.00 163014.17 67.70
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Number of Children (Unduplicated) With at Least One Service 408
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Center 09
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 41 66.25 4506.15 6875.93
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
1730 2341.75 158508.02 386.00
Other 0 0.00 0.00 0.00
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Total 1771 2408.00 163014.17 7261.93