CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1879 15337.3 567450.50 37.00
Subtotal (Total Children Is Unduplicated) 1879 15337.3 567450.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 23.50 1762.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 25.50 1415.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 53.50 4012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 173 166.50 9240.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 75.00 5625.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 123 124.00 22890.50 184.60
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 1375.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 54 57.00 5985.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 640.00 160.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 453 590.00 57093.50 96.77
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 38.50 1925.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 28 40.50 2060.76 50.88
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Total 15967.75 626604.76 39.24
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Number of Children (Unduplicated) With at Least One Service 1891
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Center 04
Flag Claims Units Chgs Paid
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R 14 23.50 869.50 0.00
U 0 0.00 0.00 0.00
B 3457 3318.75 129478.25 0.00
P 13739 12625.50 496257.01 475256.38
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 17210 15967.75 626604.76 475256.38