CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 9 9.50 351.50 37.00
Subtotal (Total Children Is Unduplicated) 9 9.50 351.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 18.00 1350.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 30.00 2212.50 73.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 160.50 12037.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 39.50 2962.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 34.00 2550.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 171.00 9435.00 55.18
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 99.00 7425.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 2.00 145.56 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 3.75 183.50 48.93
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 208 581.25 39667.06 68.24
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 10.00 2304.08 230.41
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 13.50 675.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 57 237.75 12036.99 50.63
OCCT-97530-OT SESSION BY LICENSED OT 19 81.50 5821.53 71.43
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 57 232.89 16728.60 71.83
PHY-97110HM-PT SESSION BY PT ASST 1 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 160 665.25 46529.40 69.94
SPL-92508-GROUP SPL SESSION PER CHILD 2 8.00 105.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 121.00 60.50 0.50
Subtotal (Total Children Is Unduplicated) 249 1379.39 84776.18 61.46
----------------------------------------------------------------------------------------------------------------
Total 1970.14 124794.74 63.34
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 430
----------------------------------------------------------------------------------------------------------------
Center 01
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 7 7.50 509.14 135.76
D 153 198.50 12243.75 0.00
S 0 0.00 0.00 0.00
H 15 25.50 1695.56 0.00
T 0 0.00 0.00 0.00
531 731.14 43849.24 135.76
Other 962 1007.50 66497.05 0.00
-------------------------------------------------
Total 1668 1970.14 124794.74 271.52