CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:OTHER
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
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.00 420.00 105.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 21 21.00 3428.50 163.26
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 31 350.00 8750.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 43 374.00 9350.00 25.00
PHY-97110-PT SESSION BY LICENSED PT 21 20.00 1357.60 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 28.25 1917.61 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 75 774.25 21401.61 27.64
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Total 795.25 24830.11 31.22
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Number of Children (Unduplicated) With at Least One Service 94
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 2 3.00 74.90 184.26
T 0 0.00 0.00 0.00
148 792.25 24755.21 0.00
Other 0 0.00 0.00 0.00
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Total 150 795.25 24830.11 184.26