CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1431 12532.5 463693.25 37.00
Subtotal (Total Children Is Unduplicated) 1431 12532.5 463693.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.50 262.50 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 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 24.50 1837.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 33.50 1859.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 31.00 2325.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 41.00 3075.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 160 160.50 8907.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 65.00 4875.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 216 217.00 40000.50 184.33
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 2750.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 95 110.00 11550.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 6 6.00 960.00 160.00
Subtotal (Total Children Is Unduplicated) 452 709.50 78965.00 111.30
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 14.00 700.00 50.00
Subtotal (Total Children Is Unduplicated) 19 14.00 700.00 50.00
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Total 13256.00 543358.25 40.99
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Number of Children (Unduplicated) With at Least One Service 1441
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Center 04
Flag Claims Units Chgs Paid
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R 10 13.75 508.75 0.00
U 0 0.00 0.00 0.00
B 2804 2705.50 105311.75 0.00
P 11277 10233.00 401522.75 384835.91
D 44 47.25 2791.00 27.75
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
251 256.50 33224.00 0.00
Other 0 0.00 0.00 0.00
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Total 14386 13256.00 543358.25 384863.66