CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 964 2872.75 106171.50 36.96
Subtotal (Total Children Is Unduplicated) 964 2872.75 106171.50 36.96
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 18.00 1350.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 55.00 3052.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 209.50 15712.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 45 45.00 2250.00 50.00
Subtotal (Total Children Is Unduplicated) 116 333.50 22732.56 68.16
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 0.25 12.50 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 4 3.25 162.50 50.00
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Total 3209.50 129066.56 40.21
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Number of Children (Unduplicated) With at Least One Service 964
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Center 07
Flag Claims Units Chgs Paid
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R 244 157.00 5809.00 0.00
U 0 0.00 0.00 0.00
B 4277 2844.00 115340.81 0.00
P 355 208.50 7916.75 7916.75
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 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 4876 3209.50 129066.56 7916.75