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
Bill Flag Filter:RBPU
Eligibility Filter:All
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 1142 4154.25 153707.25 37.00
Subtotal (Total Children Is Unduplicated) 1142 4154.25 153707.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 19.50 1462.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 38.00 2850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 32.50 2437.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 177 160.00 8880.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 45.00 3375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.00 1480.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.00 420.00 105.00
Subtotal (Total Children Is Unduplicated) 274 347.50 23377.00 67.27
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 16.00 800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 8 20.00 1071.52 53.58
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Total 4521.75 178155.77 39.40
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Number of Children (Unduplicated) With at Least One Service 1145
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Center 04
Flag Claims Units Chgs Paid
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R 2 2.00 87.00 0.00
U 0 0.00 0.00 0.00
B 3421 3396.00 133991.00 0.00
P 1182 1123.75 44077.77 43396.83
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 4605 4521.75 178155.77 43396.83