CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 354 903.50 33161.25 36.70
Subtotal (Total Children Is Unduplicated) 354 903.50 33161.25 36.70
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 34.50 2587.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 64.50 3579.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 55 138.00 8922.25 64.65
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 121.75 6087.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 21.75 1476.39 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 31.00 2104.28 67.88
Subtotal (Total Children Is Unduplicated) 42 174.50 9668.17 55.41
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Total 1216.00 51751.67 42.56
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Number of Children (Unduplicated) With at Least One Service 356
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Center 52
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 1848 1144.00 49087.67 0.00
P 141 72.00 2664.00 2664.00
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 1989 1216.00 51751.67 2664.00