CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 766 2477.75 91521.75 36.94
Subtotal (Total Children Is Unduplicated) 766 2477.75 91521.75 36.94
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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 29 57.50 3163.50 55.02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 103 290.00 21637.50 74.61
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 17 17.00 850.00 50.00
Subtotal (Total Children Is Unduplicated) 121 376.50 26480.53 70.33
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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 2854.75 118027.28 41.34
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Number of Children (Unduplicated) With at Least One Service 767
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Center 07
Flag Claims Units Chgs Paid
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R 18 22.75 1278.75 0.00
U 0 0.00 0.00 0.00
B 3552 2440.25 98103.78 0.00
P 229 246.75 13279.75 13279.75
D 0 0.00 0.00 0.00
S 195 109.25 4042.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
30 35.75 1322.75 0.00
Other 0 0.00 0.00 0.00
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Total 4024 2854.75 118027.28 13279.75