CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 921 3544.50 131146.50 37.00
Subtotal (Total Children Is Unduplicated) 921 3544.50 131146.50 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 3 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 17.00 1275.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 27.50 1526.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 24.50 1837.50 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 32 24.00 1800.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 119.00 6604.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 29.50 2212.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 135.00 135.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 89 89.00 16465.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 40 40.00 4200.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
Subtotal (Total Children Is Unduplicated) 220 388.00 38148.25 98.32
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 19.00 950.00 50.00
Subtotal (Total Children Is Unduplicated) 12 19.00 950.00 50.00
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Total 3951.50 170244.75 43.08
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Number of Children (Unduplicated) With at Least One Service 922
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 2877 2863.00 112114.00 0.00
P 945 899.75 34865.00 34318.43
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
189 187.75 23215.75 0.00
Other 0 0.00 0.00 0.00
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Total 4012 3951.50 170244.75 34318.43