CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 48 142.75 5281.75 37.00
Subtotal (Total Children Is Unduplicated) 48 142.75 5281.75 37.00
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Screening, Eval, and Assessment,Class #02
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 9 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 9 17.00 964.20 56.72
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Total 159.75 6245.95 39.10
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Number of Children (Unduplicated) With at Least One Service 49
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Center 05
Flag Claims Units Chgs Paid
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R 1 1.00 72.78 0.00
U 0 0.00 0.00 0.00
B 254 154.25 5954.52 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
5 4.50 218.65 0.00
Other 0 0.00 0.00 0.00
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Total 260 159.75 6245.95 0.00