CMS/EIP Fiscal Report Center: 05
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
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.01 487.74 60.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.50 487.50 75.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 6.51 188.00 28.88
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.66 32.00 48.48
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 17 25.68 1417.39 55.19
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 30 69.36 4588.02 66.15
PHY-97110-PT SESSION BY LICENSED PT 44 199.34 11474.57 57.56
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 185.48 12235.14 65.96
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 321.00 160.50 0.50
Subtotal (Total Children Is Unduplicated) 93 778.18 28497.83 36.62
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Total 803.86 29915.22 37.21
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Number of Children (Unduplicated) With at Least One Service 105
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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 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
767 803.86 29915.22 0.00
Other 0 0.00 0.00 0.00
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Total 767 803.86 29915.22 0.00