CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
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 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 19 21.00 1085.50 51.69
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 40.00 2000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 135.50 9197.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 65.00 4412.20 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 153.25 10402.61 67.88
Subtotal (Total Children Is Unduplicated) 85 393.75 26012.55 66.06
----------------------------------------------------------------------------------------------------------------
Total 414.75 27098.05 65.34
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 94
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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 16 50.00 2756.18 3130.55
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 182 364.75 24341.87 24341.87
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 198 414.75 27098.05 27472.42