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
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 70 308.00 11396.00 37.00
Subtotal (Total Children Is Unduplicated) 70 308.00 11396.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 8.00 600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 31.00 1720.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 10.00 750.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
Subtotal (Total Children Is Unduplicated) 48 76.00 5826.50 76.66
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Total 384.00 17222.50 44.85
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Number of Children (Unduplicated) With at Least One Service 70
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Center 04
Flag Claims Units Chgs Paid
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R 4 4.75 175.75 0.00
U 0 0.00 0.00 0.00
B 161 177.50 8546.00 0.00
P 118 197.75 7908.75 7371.27
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
5 4.00 592.00 0.00
Other 0 0.00 0.00 0.00
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Total 288 384.00 17222.50 7371.27