CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 55 187.00 6919.00 37.00
Subtotal (Total Children Is Unduplicated) 55 187.00 6919.00 37.00
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Screening, Eval, and Assessment,Class #02
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 11 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 16 24.00 1360.36 56.68
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
Subtotal (Total Children Is Unduplicated) 1 3.00 203.64 67.88
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Total 214.00 8483.00 39.64
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Number of Children (Unduplicated) With at Least One Service 56
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Center 05
Flag Claims Units Chgs Paid
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R 13 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 315 187.00 6919.00 0.00
P 0 0.00 0.00 0.00
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
17 14.00 867.99 0.00
Other 0 0.00 0.00 0.00
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Total 345 214.00 8483.00 0.00