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:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 16 16.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 16 16.00 0.00 0.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.00 14430.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.00 840.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
Subtotal (Total Children Is Unduplicated) 90 91.00 15930.00 175.05
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 73 3554.00 88850.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 40 1167.00 29175.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 41.00 2050.00 50.00
Subtotal (Total Children Is Unduplicated) 114 4762.00 120075.00 25.22
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Total 4869.00 136005.00 27.93
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Number of Children (Unduplicated) With at Least One Service 208
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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 3 3.00 225.00 0.00
P 0 0.00 0.00 0.00
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
505 4866.00 135780.00 0.00
Other 0 0.00 0.00 0.00
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Total 508 4869.00 136005.00 0.00