CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
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
Subtotal (Total Children Is Unduplicated) 19 19.50 2324.25 119.19
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Total 19.50 2324.25 119.19
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Number of Children (Unduplicated) With at Least One Service 19
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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 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
2 2.00 150.00 0.00
Other 0 0.00 0.00 0.00
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Total 19 19.50 2324.25 3524.55