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:OTHER
Eligibility Filter:Program Patients
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 1 0.25 9.25 37.00
Subtotal (Total Children Is Unduplicated) 1 0.25 9.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.00 5550.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 33 34.00 6080.00 178.82
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 53 1518.00 37950.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 848.00 21200.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 41.00 2050.00 50.00
Subtotal (Total Children Is Unduplicated) 93 2407.00 61200.00 25.43
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Total 2441.25 67289.25 27.56
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Number of Children (Unduplicated) With at Least One Service 127
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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 3 2.25 159.25 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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
240 2439.00 67130.00 0.00
Other 0 0.00 0.00 0.00
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Total 243 2441.25 67289.25 0.00