CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 1151 4271.00 158027.00 37.00
Subtotal (Total Children Is Unduplicated) 1151 4271.00 158027.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 25.00 1387.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 34.00 2550.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 73 53.50 4012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 181 162.00 8991.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 44.50 3337.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.00 4995.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.00 945.00 105.00
Subtotal (Total Children Is Unduplicated) 263 377.50 28306.00 74.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 5.50 373.34 67.88
Subtotal (Total Children Is Unduplicated) 3 9.50 573.34 60.35
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Total 4658.00 186906.34 40.13
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Number of Children (Unduplicated) With at Least One Service 1156
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Center 04
Flag Claims Units Chgs Paid
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R 30 27.00 999.00 0.00
U 0 0.00 0.00 0.00
B 2043 2058.75 85576.25 0.00
P 2550 2572.25 100331.09 95784.71
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 4623 4658.00 186906.34 95784.71