CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 703 5004.25 185157.25 37.00
Subtotal (Total Children Is Unduplicated) 703 5004.25 185157.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.50 862.50 69.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 6.00 450.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 28 28.00 2146.98 76.68
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 11 12.00 651.96 54.33
SCREEN-T1023-INTERDISCIPLINARY SCREENING 33 38.00 1900.00 50.00
Subtotal (Total Children Is Unduplicated) 52 118.50 7583.44 64.00
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Total 5122.75 192740.69 37.62
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Number of Children (Unduplicated) With at Least One Service 703
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Center 05
Flag Claims Units Chgs Paid
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R 70 71.75 4671.79 0.00
U 0 0.00 0.00 0.00
B 9352 5051.00 188068.90 250.00
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 9422 5122.75 192740.69 250.00