CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 959 3760.50 139138.50 37.00
Subtotal (Total Children Is Unduplicated) 959 3760.50 139138.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 5.00 375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 23.00 1276.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 23.00 1725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 45.50 3412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 128.00 7104.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 34.50 2587.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 77 77.00 14245.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.00 2310.00 105.00
Subtotal (Total Children Is Unduplicated) 216 370.00 34535.50 93.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 15.00 750.00 50.00
Subtotal (Total Children Is Unduplicated) 8 15.00 750.00 50.00
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Total 4145.50 174424.00 42.08
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Number of Children (Unduplicated) With at Least One Service 965
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Center 04
Flag Claims Units Chgs Paid
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R 24 21.00 777.00 0.00
U 0 0.00 0.00 0.00
B 1771 1789.25 73570.75 0.00
P 2245 2237.25 86826.25 83086.09
D 1 0.50 37.50 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
104 97.50 13212.50 0.00
Other 0 0.00 0.00 0.00
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Total 4145 4145.50 174424.00 83086.09