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: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 69 292.00 10804.00 37.00
Subtotal (Total Children Is Unduplicated) 69 292.00 10804.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 24.50 1359.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 3.50 262.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 38 60.50 5810.75 96.05
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Total 352.50 16614.75 47.13
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Number of Children (Unduplicated) With at Least One Service 69
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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 189 255.00 10643.25 0.00
P 49 69.75 2656.75 2656.75
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
17 18.75 2981.75 0.00
Other 0 0.00 0.00 0.00
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Total 258 352.50 16614.75 2656.75