CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 62 153.75 5688.75 37.00
Subtotal (Total Children Is Unduplicated) 62 153.75 5688.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 3.00 166.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
Subtotal (Total Children Is Unduplicated) 6 8.00 1051.50 131.44
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 25.00 1250.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 8.00 543.04 67.88
Subtotal (Total Children Is Unduplicated) 3 33.00 1793.04 54.33
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Total 194.75 8533.29 43.82
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Number of Children (Unduplicated) With at Least One Service 62
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Center 04
Flag Claims Units Chgs Paid
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R 23 20.25 749.25 0.00
U 0 0.00 0.00 0.00
B 124 75.25 2915.75 0.00
P 90 53.25 1970.25 1970.25
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 9 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
14 13.00 1105.00 0.00
Other 0 0.00 0.00 0.00
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Total 260 194.75 8533.29 3763.29