CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 60 137.25 5078.25 37.00
Subtotal (Total Children Is Unduplicated) 60 137.25 5078.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.00 55.50 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 2 2.00 370.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 8 11.00 1085.50 98.68
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.00 150.00 50.00
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Total 151.25 6313.75 41.74
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Number of Children (Unduplicated) With at Least One Service 61
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 175 112.50 4380.75 0.00
P 45 30.25 1147.50 1147.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 3.00 150.00 150.00
T 0 0.00 0.00 0.00
6 5.50 635.50 0.00
Other 0 0.00 0.00 0.00
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Total 227 151.25 6313.75 1297.50