CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
Subtotal (Total Children Is Unduplicated) 4 3.50 463.00 132.29
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 7.50 509.10 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 1 11.50 780.62 67.88
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Total 15.00 1243.62 82.91
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Number of Children (Unduplicated) With at Least One Service 5
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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 4 3.50 463.00 965.97
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 4 11.50 780.62 780.62
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 8 15.00 1243.62 1746.59