CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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 2 2.00 111.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.00 277.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.00 4070.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 18.00 873.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 59 71.00 6741.00 94.94
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 204.50 13881.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 22 95.00 6448.60 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 179.50 12184.46 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 26.50 1439.48 54.32
Subtotal (Total Children Is Unduplicated) 86 510.50 34204.00 67.00
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Total 581.50 40945.00 70.41
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Number of Children (Unduplicated) With at Least One Service 118
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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 35 36.00 5043.50 8398.40
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 258 545.50 35901.50 35602.74
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 293 581.50 40945.00 44001.14