CMS/EIP Fiscal Report Center: 52
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 3 2.00 74.00 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 48.02 3562.08 74.18
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 66.00 3663.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 81 167.02 10472.33 62.70
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 123.45 6175.00 50.02
OCCT-97530-OT SESSION BY LICENSED OT 38 155.71 10759.61 69.10
OCCT-97530HM-OT SESSION BY OT ASST 1 12.00 651.84 54.32
PHY-97110-PT SESSION BY LICENSED PT 36 179.23 12192.15 68.03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 103 424.78 28987.39 68.24
Subtotal (Total Children Is Unduplicated) 157 896.17 58815.99 65.63
----------------------------------------------------------------------------------------------------------------
Total 1065.19 69362.32 65.12
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 210
----------------------------------------------------------------------------------------------------------------
Center 52
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 5 4.92 623.47 623.47
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 38 69.75 4936.05 0.00
T 0 0.00 0.00 0.00
463 990.52 63802.80 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 506 1065.19 69362.32 623.47