CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 34 14.25 527.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 16 16.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 60 131.50 4865.50 37.00
Subtotal (Total Children Is Unduplicated) 60 163.75 5466.75 33.38
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 3.00 150.00 50.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 218.34 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 9 20.00 1069.24 53.46
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Total 183.75 6535.99 35.57
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Number of Children (Unduplicated) With at Least One Service 60
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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 199 110.75 4110.90 0.00
P 1 1.00 50.00 50.00
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
129 72.00 2375.09 0.00
Other 0 0.00 0.00 0.00
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Total 329 183.75 6535.99 50.00