CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 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
Subtotal (Total Children Is Unduplicated) 127 147.50 20199.46 136.95
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Total 147.50 20199.46 136.95
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Number of Children (Unduplicated) With at Least One Service 127
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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 126 128.50 17384.46 26044.85
D 8 8.00 1490.00 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
11 11.00 1325.00 0.00
Other 0 0.00 0.00 0.00
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Total 145 147.50 20199.46 26044.85