CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Not Part C
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 40 131.25 4847.00 36.93
Subtotal (Total Children Is Unduplicated) 40 131.25 4847.00 36.93
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.00 999.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 48.50 3637.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 26 72.50 5009.28 69.09
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Total 203.75 9856.28 48.37
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Number of Children (Unduplicated) With at Least One Service 41
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Center 07
Flag Claims Units Chgs Paid
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R 3 4.00 224.00 0.00
U 0 0.00 0.00 0.00
B 154 144.75 6281.28 0.00
P 36 46.25 2877.25 2877.25
D 0 0.00 0.00 0.00
S 6 2.75 101.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4 6.00 372.00 0.00
Other 0 0.00 0.00 0.00
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Total 203 203.75 9856.28 2877.25