CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 4 4.00 200.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
Subtotal (Total Children Is Unduplicated) 5 14.00 893.64 63.83
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Total 14.00 893.64 63.83
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Number of Children (Unduplicated) With at Least One Service 5
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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
11 11.00 668.64 0.00
Other 0 0.00 0.00 0.00
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Total 11 11.00 668.64 0.00
Center 06
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
2 14.00 893.64 0.00
Other 0 0.00 0.00 0.00
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Total 2 14.00 893.64 0.00