CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 50 138.00 5106.00 37.00
Subtotal (Total Children Is Unduplicated) 50 138.00 5106.00 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 4 4.00 291.12 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.00 250.75 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 11 24.00 1491.87 62.16
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Total 162.00 6597.87 40.73
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Number of Children (Unduplicated) With at Least One Service 50
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Center 05
Flag Claims Units Chgs Paid
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R 16 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 272 148.75 5906.69 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
6 6.00 422.93 0.00
Other 0 0.00 0.00 0.00
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Total 294 162.00 6597.87 0.00