CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 87 601.75 22246.25 36.97
Subtotal (Total Children Is Unduplicated) 87 601.75 22246.25 36.97
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
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 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 9 11.50 1414.00 122.96
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 23.50 1175.00 50.00
Subtotal (Total Children Is Unduplicated) 5 23.50 1175.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 636.75 24835.25 39.00
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 88
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 159 117.75 4437.75 0.00
P 725 490.00 18576.00 18244.84
D 2 2.00 92.50 37.00
S 0 0.00 0.00 0.00
H 7 22.00 1100.00 1100.00
T 0 0.00 0.00 0.00
5 4.25 601.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 899 636.75 24835.25 19381.84