CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 1021 3976.00 147075.00 36.99
Subtotal (Total Children Is Unduplicated) 1021 3976.00 147075.00 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 12 11.00 825.00 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 52 28.00 2100.00 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 55 38.00 2850.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 154 141.50 7799.25 55.12
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 57.50 4312.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 104 104.00 19240.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.00 2835.00 105.00
Subtotal (Total Children Is Unduplicated) 257 453.00 42913.25 94.73
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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 4431.00 190088.25 42.90
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Number of Children (Unduplicated) With at Least One Service 1035
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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 1480 1615.00 63942.00 0.00
P 2500 2610.25 108373.00 101993.90
D 0 0.00 0.00 0.00
S 1 2.00 74.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
190 203.75 17699.25 0.00
Other 0 0.00 0.00 0.00
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Total 4171 4431.00 190088.25 101993.90