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
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 1203 4294.75 158905.75 37.00
Subtotal (Total Children Is Unduplicated) 1203 4294.75 158905.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 18.50 1387.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 14.50 804.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 35.50 2626.00 73.97
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 45.50 3412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 190 165.00 9103.00 55.17
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 61.50 4612.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 277 355.50 23181.25 65.21
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 6.00 300.00 50.00
Subtotal (Total Children Is Unduplicated) 5 6.00 300.00 50.00
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Total 4656.25 182387.00 39.17
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Number of Children (Unduplicated) With at Least One Service 1204
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Center 04
Flag Claims Units Chgs Paid
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R 322 337.50 13468.00 0.00
U 0 0.00 0.00 0.00
B 2034 2071.75 85554.00 0.00
P 2173 2247.00 83365.00 83186.18
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 4529 4656.25 182387.00 83186.18