CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 862 3124.25 115597.25 37.00
Subtotal (Total Children Is Unduplicated) 862 3124.25 115597.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.50 112.50 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 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.50 1012.50 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 21 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 71.00 3940.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 19.00 1425.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 56 56.00 10360.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 36 36.00 3780.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
Subtotal (Total Children Is Unduplicated) 148 243.50 24500.75 100.62
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 4.00 200.00 50.00
Subtotal (Total Children Is Unduplicated) 4 4.00 200.00 50.00
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Total 3371.75 140298.00 41.61
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Number of Children (Unduplicated) With at Least One Service 869
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Center 04
Flag Claims Units Chgs Paid
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R 8 12.75 471.75 0.00
U 0 0.00 0.00 0.00
B 2427 2358.00 90845.75 0.00
P 994 869.75 33308.25 32956.56
D 2 1.75 77.75 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
123 129.50 15594.50 0.00
Other 0 0.00 0.00 0.00
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Total 3554 3371.75 140298.00 32984.31