CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1056 3827.75 141626.75 37.00
Subtotal (Total Children Is Unduplicated) 1056 3827.75 141626.75 37.00
----------------------------------------------------------------------------------------------------------------
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 4 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 13.50 749.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 23.50 1762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 36.50 2737.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 144 128.00 7104.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 46.00 3450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 87 87.00 16095.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.00 2415.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
Subtotal (Total Children Is Unduplicated) 229 390.00 37035.75 94.96
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 2 2.00 100.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 4219.75 178762.50 42.36
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1059
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 283 303.25 11974.25 0.00
U 0 0.00 0.00 0.00
B 1704 1742.25 71514.00 0.00
P 1907 1963.75 72806.75 72670.43
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 1 1.25 46.25 0.00
211 209.25 22421.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4106 4219.75 178762.50 72670.43