CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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
CASE-CASE-NON-TCM CASE MANAGEMENT 37 16.75 619.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 9 9.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 9.25 342.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 53 158.75 5873.75 37.00
Subtotal (Total Children Is Unduplicated) 53 193.75 6835.75 35.28
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 100.00 50.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 3.00 150.45 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 11 21.00 1187.13 56.53
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Total 214.75 8022.88 37.36
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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 1 1.00 72.78 0.00
U 0 0.00 0.00 0.00
B 254 154.25 5954.52 0.00
P 0 0.00 0.00 0.00
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
124 59.50 1995.58 0.00
Other 0 0.00 0.00 0.00
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Total 379 214.75 8022.88 0.00