CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.50 256.55 73.30
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 2.00 150.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 5 10.00 697.33 69.73
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 8.50 576.98 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 3 13.50 916.38 67.88
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Total 23.50 1613.71 68.67
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Number of Children (Unduplicated) With at Least One Service 8
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Center 01
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 0 0.00 0.00 0.00
D 2 2.00 130.50 0.00
S 0 0.00 0.00 0.00
H 3 1.50 112.50 0.00
T 0 0.00 0.00 0.00
1 0.50 31.55 0.00
Other 1 1.00 75.00 0.00
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Total 7 5.00 349.55 0.00
Center 05
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 0 0.00 0.00 0.00
D 0 2.00 130.50 0.00
S 0 0.00 0.00 0.00
H 0 1.50 112.50 0.00
T 0 0.00 0.00 0.00
2 2.50 154.33 0.00
Other 0 1.00 75.00 0.00
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Total 2 7.00 472.33 0.00
Center 06
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 0 0.00 0.00 0.00
D 0 2.00 130.50 0.00
S 0 0.00 0.00 0.00
H 0 1.50 112.50 0.00
T 0 0.00 0.00 0.00
8 10.50 718.73 0.00
Other 0 1.00 75.00 0.00
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Total 8 15.00 1036.73 0.00
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 0 0.00 0.00 0.00
D 0 2.00 130.50 0.00
S 0 0.00 0.00 0.00
H 0 1.50 112.50 0.00
T 0 0.00 0.00 0.00
3 19.00 1295.71 0.00
Other 0 1.00 75.00 0.00
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Total 3 23.50 1613.71 0.00