CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 908 2703.00 99890.75 36.96
Subtotal (Total Children Is Unduplicated) 908 2703.00 99890.75 36.96
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 14.00 1050.00 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 23 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 188.50 14062.50 74.60
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
SCREEN-T1023-INTERDISCIPLINARY SCREENING 37 37.00 1850.00 50.00
Subtotal (Total Children Is Unduplicated) 102 290.50 19827.56 68.25
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EI Services,Class #03
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 3 3.00 150.00 50.00
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Total 2996.50 119868.31 40.00
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Number of Children (Unduplicated) With at Least One Service 908
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Center 07
Flag Claims Units Chgs Paid
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R 232 148.00 5476.00 0.00
U 0 0.00 0.00 0.00
B 4023 2618.75 105840.31 0.00
P 346 200.00 7374.25 7374.25
D 0 0.00 0.00 0.00
S 5 5.25 194.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
39 24.50 983.50 0.00
Other 0 0.00 0.00 0.00
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Total 4645 2996.50 119868.31 7374.25