CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 5 5.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 5 5.00 0.00 0.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 30.50 2287.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 25.50 1912.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 125.50 9412.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.50 862.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 60 80.50 6037.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 52.50 2913.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 57.00 4275.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 123 394.50 28412.58 72.02
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.50 125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 122 564.25 38301.29 67.88
PHY-97110-PT SESSION BY LICENSED PT 117 552.00 37469.76 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 17.00 923.44 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 147 632.25 42917.13 67.88
Subtotal (Total Children Is Unduplicated) 271 1769.00 119786.62 67.71
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Total 2168.50 148199.20 68.34
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Number of Children (Unduplicated) With at Least One Service 371
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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 21 17.50 1128.85 2757.02
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
1413 2151.00 147070.35 114.11
Other 0 0.00 0.00 0.00
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Total 1434 2168.50 148199.20 2871.13