CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 81.00 6075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.83 1337.25 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 117.00 6493.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.50 487.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 14.20 689.07 48.53
Subtotal (Total Children Is Unduplicated) 113 258.53 16395.07 63.42
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.00 300.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 44.75 2237.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 200.00 10000.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 31 170.99 11614.67 67.93
OCCT-97530HM-OT SESSION BY OT ASST 3 29.47 1968.85 66.81
PHY-97110-PT SESSION BY LICENSED PT 42 195.94 13359.55 68.18
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 114 597.57 40562.22 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.50 138.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 24.00 12.00 0.50
Subtotal (Total Children Is Unduplicated) 176 1295.22 80693.39 62.30
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Total 1553.75 97088.46 62.49
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Number of Children (Unduplicated) With at Least One Service 242
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Center 52
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 2 2.22 132.25 49.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 18 53.75 2957.67 0.00
T 0 0.00 0.00 0.00
682 1497.78 93998.54 0.00
Other 0 0.00 0.00 0.00
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Total 702 1553.75 97088.46 49.00