CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 72 357.75 13236.75 37.00
Subtotal (Total Children Is Unduplicated) 72 357.75 13236.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
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 21 11.50 826.00 71.83
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 34.00 1832.50 53.90
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 14.50 1087.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.00 3330.00 185.00
Subtotal (Total Children Is Unduplicated) 56 89.50 7919.00 88.48
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Total 447.25 21155.75 47.30
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Number of Children (Unduplicated) With at Least One Service 72
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Center 04
Flag Claims Units Chgs Paid
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R 16 14.00 744.50 0.00
U 0 0.00 0.00 0.00
B 174 228.50 10171.50 0.00
P 107 172.50 6382.50 6382.50
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
28 32.25 3857.25 0.00
Other 0 0.00 0.00 0.00
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Total 325 447.25 21155.75 6382.50