CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 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 363 1159.25 42892.25 37.00
Subtotal (Total Children Is Unduplicated) 363 1159.25 42892.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.50 412.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 11 22.50 1551.70 68.96
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Total 1181.75 44443.95 37.61
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Number of Children (Unduplicated) With at Least One Service 363
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Center 05
Flag Claims Units Chgs Paid
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R 20 20.00 1364.20 0.00
U 0 0.00 0.00 0.00
B 2209 1161.75 43079.75 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 2229 1181.75 44443.95 0.00