CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 53 109.75 4060.75 37.00
Subtotal (Total Children Is Unduplicated) 53 109.75 4060.75 37.00
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Screening, Eval, and Assessment,Class #02
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 8 16.00 846.46 52.90
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Total 125.75 4907.21 39.02
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Number of Children (Unduplicated) With at Least One Service 53
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Center 05
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 199 110.75 4110.90 0.00
P 1 1.00 50.00 50.00
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
14 14.00 746.31 0.00
Other 0 0.00 0.00 0.00
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Total 214 125.75 4907.21 50.00