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
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 1184 4449.50 164594.50 36.99
Subtotal (Total Children Is Unduplicated) 1184 4449.50 164594.50 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.00 225.00 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 7 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 12.50 937.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 32.00 1776.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 34.00 2550.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 38.00 25.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 48.00 3600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 177.00 9769.50 55.19
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 67.00 5025.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 55 55.00 10175.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.00 1365.00 105.00
Subtotal (Total Children Is Unduplicated) 308 452.50 36373.50 80.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 1 2.00 100.00 50.00
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Total 4904.00 201068.00 41.00
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Number of Children (Unduplicated) With at Least One Service 1203
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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 1799 1907.50 75726.75 0.00
P 2979 2996.50 125341.25 117333.63
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 4778 4904.00 201068.00 117333.63