CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
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 2 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 6 18.00 1301.80 72.32
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 2 5.50 373.34 67.88
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Total 23.50 1675.14 71.28
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Number of Children (Unduplicated) With at Least One Service 8
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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 1 1.00 185.00 345.33
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 1 1.00 185.00 345.33
Center 05
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 0 1.00 185.00 345.33
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
4 4.00 200.30 0.00
Other 0 0.00 0.00 0.00
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Total 4 5.00 385.30 345.33
Center 06
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 0 1.00 185.00 345.33
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 5.00 268.18 0.00
Other 0 0.00 0.00 0.00
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Total 2 6.00 453.18 345.33
Center 10
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 0 1.00 185.00 345.33
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
9 18.00 1184.68 0.00
Other 0 0.00 0.00 0.00
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Total 9 19.00 1369.68 345.33
Center 54
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 0 1.00 185.00 345.33
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
1 22.50 1490.14 0.00
Other 0 0.00 0.00 0.00
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Total 1 23.50 1675.14 345.33