CMS/EIP Fiscal Report Center: 09
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 2 1.00 37.00 37.00
Subtotal (Total Children Is Unduplicated) 2 1.00 37.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 51.50 3862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 39.00 2925.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 166.50 12487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 56 70.50 5287.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 77.50 4301.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 75.50 5662.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 172 511.50 36645.00 71.64
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 54.90 54.90
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.50 275.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 115 623.75 42340.15 67.88
PHY-97110-PT SESSION BY LICENSED PT 126 630.25 42781.37 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 11.00 597.52 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 173 766.25 52013.05 67.88
Subtotal (Total Children Is Unduplicated) 285 2037.75 138061.99 67.75
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Total 2550.25 174743.99 68.52
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Number of Children (Unduplicated) With at Least One Service 428
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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 24 12.25 817.97 1761.60
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
1648 2538.00 173926.02 0.00
Other 0 0.00 0.00 0.00
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Total 1672 2550.25 174743.99 1761.60