CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 555.00 185.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 8 8.50 835.00 98.24
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 14.00 700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 40.78 2737.68 67.13
PHY-97110-PT SESSION BY LICENSED PT 4 22.00 1493.36 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 17.50 1187.90 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.50 19.80 13.20
Subtotal (Total Children Is Unduplicated) 24 95.78 6138.74 64.09
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Total 104.28 6973.74 66.88
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Number of Children (Unduplicated) With at Least One Service 30
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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 8 20.50 1531.90 1508.14
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 41 83.78 5441.84 5525.36
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 49 104.28 6973.74 7033.50