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: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 69 291.75 10794.75 37.00
Subtotal (Total Children Is Unduplicated) 69 291.75 10794.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 33.00 1831.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 8.50 637.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.00 4255.00 185.00
Subtotal (Total Children Is Unduplicated) 50 81.50 7999.00 98.15
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Total 373.25 18793.75 50.35
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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 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 115 179.75 7556.50 0.00
P 127 166.00 8147.75 7069.17
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
23 27.50 3089.50 0.00
Other 0 0.00 0.00 0.00
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Total 265 373.25 18793.75 7069.17