CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 23 23.50 2518.25 107.16
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 16 54.00 3665.52 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 5.50 298.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 16 44.50 3020.66 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 4.00 217.28 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 22.37 1463.16 65.41
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.50 46.20 13.20
Subtotal (Total Children Is Unduplicated) 40 139.87 9011.58 64.43
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Total 163.37 11529.83 70.57
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Number of Children (Unduplicated) With at Least One Service 58
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Center 04
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 17 17.50 2174.25 3524.55
D 8 17.00 1120.06 1153.96
S 0 0.00 0.00 0.00
H 53 126.87 8085.52 8094.74
T 0 0.00 0.00 0.00
2 2.00 150.00 0.00
Other 0 0.00 0.00 0.00
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Total 80 163.37 11529.83 12773.25