CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 901 3405.00 125985.00 37.00
Subtotal (Total Children Is Unduplicated) 901 3405.00 125985.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 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 14 13.50 1012.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 17.00 943.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 74.00 4107.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 30.50 2287.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 73 73.00 13360.50 183.02
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 28 28.00 2940.00 105.00
Subtotal (Total Children Is Unduplicated) 161 272.50 28188.50 103.44
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 2 3.00 150.00 50.00
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Total 3680.50 154323.50 41.93
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Number of Children (Unduplicated) With at Least One Service 904
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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 3535 3365.50 125626.00 0.00
P 118 103.00 8177.00 6961.48
D 35 36.00 2315.50 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
127 127.50 16410.50 0.00
Other 0 0.00 0.00 0.00
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Total 3837 3680.50 154323.50 6961.48