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: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 77 371.00 13727.00 37.00
Subtotal (Total Children Is Unduplicated) 77 371.00 13727.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 40.00 2220.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 12.00 900.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.00 3885.00 185.00
Subtotal (Total Children Is Unduplicated) 60 97.50 8813.25 90.39
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Total 468.50 22540.25 48.11
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Number of Children (Unduplicated) With at Least One Service 77
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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 252 317.75 13694.50 0.00
P 85 119.50 5025.50 4891.13
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
25 31.25 3820.25 0.00
Other 0 0.00 0.00 0.00
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Total 362 468.50 22540.25 4891.13