CMS/EIP Fiscal Report Center: 55
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 13.75 508.75 37.00
Subtotal (Total Children Is Unduplicated) 7 14.75 508.75 34.49
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 5.50 275.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 4 6.00 375.00 62.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 56.46 4234.69 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.03 1352.18 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 15.00 1125.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.50 1337.50 86.29
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 1.21 58.50 48.35
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 5.41 262.50 48.52
Subtotal (Total Children Is Unduplicated) 77 146.11 10166.20 69.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 50 234.38 15914.65 67.90
OCCT-97530HM-OT SESSION BY OT ASST 1 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 27 132.70 8980.10 67.67
PHY-97110HM-PT SESSION BY PT ASST 4 15.00 814.80 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 65 306.51 20808.02 67.89
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 103 697.59 46994.09 67.37
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Total 858.45 57669.04 67.18
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Number of Children (Unduplicated) With at Least One Service 156
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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 18 19.00 1414.56 1414.56
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
1235 839.45 56254.48 0.00
Other 0 0.00 0.00 0.00
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Total 1253 858.45 57669.04 1414.56