CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 71 196.00 7252.00 37.00
Subtotal (Total Children Is Unduplicated) 71 196.00 7252.00 37.00
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Screening, Eval, and Assessment,Class #02
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 2.50 138.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 740.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
Subtotal (Total Children Is Unduplicated) 6 11.00 1256.75 114.25
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 22.00 1100.00 50.00
Subtotal (Total Children Is Unduplicated) 3 22.00 1100.00 50.00
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Total 229.00 9608.75 41.96
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Number of Children (Unduplicated) With at Least One Service 71
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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 117 73.75 2785.25 0.00
P 188 129.50 5436.75 4886.81
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 6 22.00 1100.00 1100.00
T 0 0.00 0.00 0.00
4 3.75 286.75 0.00
Other 0 0.00 0.00 0.00
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Total 315 229.00 9608.75 5986.81