CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1086 4045.00 149646.50 37.00
Subtotal (Total Children Is Unduplicated) 1086 4045.00 149646.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 12.50 937.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 60.50 3357.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 35.00 2625.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.00 2035.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 133 170.50 12905.00 75.69
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 11.00 550.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 5 13.00 685.76 52.75
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Total 4228.50 163237.26 38.60
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Number of Children (Unduplicated) With at Least One Service 1087
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Center 04
Flag Claims Units Chgs Paid
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R 22 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 4203 4045.00 150879.50 0.00
P 148 135.00 10563.26 8954.83
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 4373 4228.50 163237.26 8954.83