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
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 791 2481.50 91651.25 36.93
Subtotal (Total Children Is Unduplicated) 791 2481.50 91651.25 36.93
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 71.50 3940.50 55.11
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 120 338.50 25275.00 74.67
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 20 20.00 1000.00 50.00
Subtotal (Total Children Is Unduplicated) 143 443.00 31117.81 70.24
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 2 0.50 25.00 50.00
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Total 2925.00 122794.06 41.98
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Number of Children (Unduplicated) With at Least One Service 796
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Center 07
Flag Claims Units Chgs Paid
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R 21 26.75 1502.75 0.00
U 0 0.00 0.00 0.00
B 3727 2605.25 105134.31 0.00
P 265 293.00 16157.00 16157.00
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 4013 2925.00 122794.06 16157.00