CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 965 2793.25 103239.25 36.96
Subtotal (Total Children Is Unduplicated) 965 2793.25 103239.25 36.96
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 100.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 58.50 3246.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 323.00 24225.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 30 30.00 1500.00 50.00
Subtotal (Total Children Is Unduplicated) 139 426.50 30044.53 70.44
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EI Services,Class #03
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.00 50.00 50.00
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Total 3220.75 133333.78 41.40
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Number of Children (Unduplicated) With at Least One Service 965
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Center 07
Flag Claims Units Chgs Paid
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R 21 10.50 521.50 0.00
U 0 0.00 0.00 0.00
B 1178 729.50 27774.50 0.00
P 3496 2480.75 105037.78 105037.78
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 4695 3220.75 133333.78 105037.78