CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 517 2238.25 82815.25 37.00
Subtotal (Total Children Is Unduplicated) 517 2238.25 82815.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.50 1312.50 70.95
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 40.50 40.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 23 33.50 2350.00 70.15
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.00 1357.60 67.88
Subtotal (Total Children Is Unduplicated) 4 20.00 1357.60 67.88
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Total 2291.75 86522.85 37.75
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Number of Children (Unduplicated) With at Least One Service 518
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Center 51
Flag Claims Units Chgs Paid
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R 4 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 3208 2290.00 86458.10 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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 3212 2291.75 86522.85 0.00