CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 353 1163.25 43040.25 37.00
Subtotal (Total Children Is Unduplicated) 353 1163.25 43040.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 7 12.00 649.10 54.09
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 3 5.50 373.34 67.88
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Total 1180.75 44062.69 37.32
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Number of Children (Unduplicated) With at Least One Service 353
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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 2001 1056.25 39183.40 0.00
P 3 2.00 74.00 27.75
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 1 2.25 83.25 0.00
181 120.25 4722.04 0.00
Other 0 0.00 0.00 0.00
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Total 2186 1180.75 44062.69 27.75