CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 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 350 1062.50 39109.00 36.81
Subtotal (Total Children Is Unduplicated) 350 1062.50 39109.00 36.81
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 27.50 2062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.50 1012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 103.50 5744.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 90 170.00 10550.50 62.06
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 69.75 3487.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 4 30.75 2087.31 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 67.50 4581.90 67.88
Subtotal (Total Children Is Unduplicated) 42 170.00 10292.47 60.54
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Total 1402.50 59951.97 42.75
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Number of Children (Unduplicated) With at Least One Service 354
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Center 52
Flag Claims Units Chgs Paid
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R 8 8.00 534.34 0.00
U 0 0.00 0.00 0.00
B 1351 851.50 35426.92 9.25
P 833 543.00 23990.71 23990.71
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 2192 1402.50 59951.97 23999.96