CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 337 1154.25 42707.25 37.00
Subtotal (Total Children Is Unduplicated) 337 1154.25 42707.25 37.00
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
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 5 5.00 363.90 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 6 12.00 839.05 69.92
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Total 1166.25 43546.30 37.34
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Number of Children (Unduplicated) With at Least One Service 337
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Center 05
Flag Claims Units Chgs Paid
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R 42 28.25 1045.25 0.00
U 0 0.00 0.00 0.00
B 1940 1052.50 39275.62 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
124 85.50 3225.43 0.00
Other 0 0.00 0.00 0.00
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Total 2106 1166.25 43546.30 0.00