CMS/EIP Fiscal Report Center: 07
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 911 2672.25 98762.25 36.96
Subtotal (Total Children Is Unduplicated) 911 2672.25 98762.25 36.96
----------------------------------------------------------------------------------------------------------------
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 25 48.50 2691.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 286.00 21412.50 74.87
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 25 25.00 1250.00 50.00
Subtotal (Total Children Is Unduplicated) 121 374.50 26427.03 70.57
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Total 3047.75 125239.28 41.09
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 911
----------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 10.50 521.50 0.00
U 0 0.00 0.00 0.00
B 1136 697.25 26531.25 0.00
P 3309 2282.50 95849.53 95849.53
D 0 0.00 0.00 0.00
S 64 35.00 1295.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
31 22.50 1042.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4561 3047.75 125239.28 95849.53