CMS/EIP Fiscal Report Center: 55
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 2.75 101.75 37.00
Subtotal (Total Children Is Unduplicated) 2 2.75 101.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 10.00 550.00 55.00
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.00 100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 250.00 250.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 77.07 5780.33 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 25.00 1875.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 19.50 4225.00 216.67
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 85 166.07 14481.83 87.20
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 158.12 158.12
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 37 179.27 12169.42 67.88
OCCT-97530HM-OT SESSION BY OT ASST 5 18.78 1020.26 54.33
PHY-97110-PT SESSION BY LICENSED PT 18 88.53 6010.10 67.89
PHY-97110HM-PT SESSION BY PT ASST 9 23.00 1250.08 54.35
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 263.37 17877.66 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.50 33.00 13.20
Subtotal (Total Children Is Unduplicated) 106 583.95 38893.64 66.60
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Total 752.77 53477.22 71.04
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Number of Children (Unduplicated) With at Least One Service 168
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Center 55
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 1 1.50 250.00 162.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 17 17.00 4075.00 0.00
T 0 0.00 0.00 0.00
1009 734.27 49152.22 0.00
Other 0 0.00 0.00 0.00
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Total 1027 752.77 53477.22 162.50