CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 939 7926.25 293129.25 36.98
Subtotal (Total Children Is Unduplicated) 939 7926.25 293129.25 36.98
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 15.00 1125.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 40.50 3037.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.00 525.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 78.00 5850.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.00 121.50 40.50
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.00 236.53 78.84
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 106 158.50 11663.03 73.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 217.50 10875.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 29.00 1804.48 62.22
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 34 250.50 12786.96 51.05
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Total 8335.25 317579.24 38.10
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Number of Children (Unduplicated) With at Least One Service 940
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Center 51
Flag Claims Units Chgs Paid
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R 3 3.00 187.00 0.00
U 0 0.00 0.00 0.00
B 12307 8331.25 317324.36 0.00
P 1 1.00 67.88 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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 12311 8335.25 317579.24 0.00