CMS/EIP Fiscal Report Center: 05
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 8.00 400.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.00 525.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 10 10.00 782.37 78.24
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 7.00 376.13 53.73
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 15 49.00 3098.00 63.22
----------------------------------------------------------------------------------------------------------------
Total 49.00 3098.00 63.22
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15
----------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
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
49 49.00 3098.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 49 49.00 3098.00 0.00