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
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 369 1257.00 46509.00 37.00
Subtotal (Total Children Is Unduplicated) 369 1257.00 46509.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 14 29.00 1810.06 62.42
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.00 150.00 50.00
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Total 1289.00 48469.06 37.60
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Number of Children (Unduplicated) With at Least One Service 369
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Center 05
Flag Claims Units Chgs Paid
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R 32 32.00 1960.06 0.00
U 0 0.00 0.00 0.00
B 2315 1257.00 46509.00 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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 2347 1289.00 48469.06 0.00