CMS/EIP Fiscal Report Center: 51
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
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 9.50 675.00 71.05
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 28 40.00 2274.75 56.87
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.75 237.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 26.00 1300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 28 129.25 8773.49 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 35 158.25 10742.01 67.88
PHY-97110HM-PT SESSION BY PT ASST 5 25.50 1425.84 55.92
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 48 213.00 14458.44 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.00 52.80 13.20
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 78 571.75 37553.04 65.68
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Total 611.75 39827.79 65.10
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Number of Children (Unduplicated) With at Least One Service 86
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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 34 102.50 6099.19 6099.19
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
248 509.25 33728.60 0.00
Other 0 0.00 0.00 0.00
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Total 282 611.75 39827.79 6099.19