CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 87 409.75 15160.75 37.00
Subtotal (Total Children Is Unduplicated) 87 409.75 15160.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 13.00 975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 15.00 1125.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.00 3145.00 185.00
Subtotal (Total Children Is Unduplicated) 62 99.00 8476.00 85.62
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Total 508.75 23636.75 46.46
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Number of Children (Unduplicated) With at Least One Service 87
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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 193 239.50 11158.50 0.00
P 183 255.25 10036.25 9545.04
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
14 14.00 2442.00 0.00
Other 0 0.00 0.00 0.00
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Total 390 508.75 23636.75 9545.04