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:Not Part C
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 230 1371.75 50754.75 37.00
Subtotal (Total Children Is Unduplicated) 230 1371.75 50754.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 12.50 937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 41.50 2303.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 9.00 675.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 64 65.00 12120.00 186.46
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 106 145.50 17319.75 119.04
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Total 1517.25 68074.50 44.87
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Number of Children (Unduplicated) With at Least One Service 234
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Center 04
Flag Claims Units Chgs Paid
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R 3 9.00 333.00 0.00
U 0 0.00 0.00 0.00
B 211 284.50 11921.75 0.00
P 848 1177.50 48897.50 44914.87
D 6 6.00 333.00 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
37 40.25 6589.25 0.00
Other 0 0.00 0.00 0.00
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Total 1105 1517.25 68074.50 44914.87