CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 1 0.75 27.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 53.00 3901.00 73.60
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.00 975.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 12.00 900.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 39.00 2925.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 162.50 12187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 33.00 2475.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 85 112.00 8400.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 41.50 2303.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 78.50 5887.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 174 554.50 40488.25 73.02
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 139 666.50 45242.02 67.88
PHY-97110-PT SESSION BY LICENSED PT 107 536.25 36400.65 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 23.00 1249.36 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 160 661.25 44885.65 67.88
Subtotal (Total Children Is Unduplicated) 281 1887.00 127777.68 67.71
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Total 2442.25 168293.68 68.91
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Number of Children (Unduplicated) With at Least One Service 424
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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 26 58.00 3958.40 7725.97
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
1662 2384.25 164335.28 0.00
Other 0 0.00 0.00 0.00
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Total 1688 2442.25 168293.68 7725.97