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
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 388 1275.50 47193.50 37.00
Subtotal (Total Children Is Unduplicated) 388 1275.50 47193.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 10 19.00 1136.98 59.84
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Total 1294.50 48330.48 37.34
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Number of Children (Unduplicated) With at Least One Service 388
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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 2378 1291.50 48183.70 0.00
P 3 2.00 74.00 27.75
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 2382 1294.50 48330.48 27.75