CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 365 1326.00 49062.00 37.00
Subtotal (Total Children Is Unduplicated) 365 1326.00 49062.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 1 1.00 50.15 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 8 11.00 674.71 61.34
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 1 2.00 135.76 67.88
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Total 1339.00 49872.47 37.25
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Number of Children (Unduplicated) With at Least One Service 365
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Center 05
Flag Claims Units Chgs Paid
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R 58 29.00 1073.00 0.00
U 0 0.00 0.00 0.00
B 2192 1192.25 44131.75 0.00
P 0 0.00 0.00 0.00
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
197 117.75 4667.72 0.00
Other 0 0.00 0.00 0.00
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Total 2447 1339.00 49872.47 0.00