CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 13.00 650.00 50.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 309.31 77.33
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 7 9.00 488.97 54.33
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 10 35.00 1886.28 53.89
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Total 35.00 1886.28 53.89
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Number of Children (Unduplicated) With at Least One Service 10
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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 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
35 35.00 1886.28 0.00
Other 0 0.00 0.00 0.00
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Total 35 35.00 1886.28 0.00