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
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 370 1164.25 43077.25 37.00
Subtotal (Total Children Is Unduplicated) 370 1164.25 43077.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 4 6.50 437.65 67.33
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Total 1170.75 43514.90 37.17
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Number of Children (Unduplicated) With at Least One Service 370
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Center 05
Flag Claims Units Chgs Paid
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R 149 95.75 3542.75 0.00
U 0 0.00 0.00 0.00
B 2040 1074.00 39922.15 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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 2190 1170.75 43514.90 50.00