CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 59 122.50 4532.50 37.00
Subtotal (Total Children Is Unduplicated) 59 122.50 4532.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 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-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 2 4.00 291.00 72.75
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 1 8.00 400.00 50.00
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Total 134.50 5223.50 38.84
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Number of Children (Unduplicated) With at Least One Service 59
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 111 85.75 3259.25 0.00
P 59 38.75 1490.25 1490.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 2 8.00 400.00 400.00
T 0 0.00 0.00 0.00
2 1.25 46.25 0.00
Other 0 0.00 0.00 0.00
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Total 175 134.50 5223.50 1890.25