CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 6 6.00 300.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 17.00 1275.00 75.00
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.00 25.96 25.96
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 79 79.00 14615.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.00 1365.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 6.08 294.88 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 137 163.58 20979.34 128.25
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 35.00 1750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 29 130.78 8736.66 66.80
OCCT-97530HM-OT SESSION BY OT ASST 4 5.50 298.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 19 79.50 5353.98 67.35
PHY-97110HM-PT SESSION BY PT ASST 1 6.00 325.92 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 73.37 4678.27 63.76
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 74 365.15 21224.59 58.13
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Total 528.73 42203.93 79.82
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Number of Children (Unduplicated) With at Least One Service 178
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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 135 184.50 18930.40 27590.79
D 16 25.00 2610.06 1153.96
S 0 0.00 0.00 0.00
H 149 308.23 19338.47 19501.04
T 0 0.00 0.00 0.00
11 11.00 1325.00 0.00
Other 0 0.00 0.00 0.00
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Total 311 528.73 42203.93 48245.79