CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 3.75 138.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 22.50 832.50 37.00
Subtotal (Total Children Is Unduplicated) 7 26.75 989.75 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 19.50 1462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 14.50 1087.50 75.00
Subtotal (Total Children Is Unduplicated) 24 55.00 3715.50 67.55
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 179.95 179.95
Subtotal (Total Children Is Unduplicated) 1 1.00 179.95 179.95
----------------------------------------------------------------------------------------------------------------
Total 82.75 4885.20 59.04
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 31
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 3 3.50 129.50 0.00
H 10 11.50 813.75 0.00
T 17 23.00 1559.25 1559.25
30 24.25 1040.20 0.00
Other 14 20.50 1342.50 0.00
-------------------------------------------------
Total 74 82.75 4885.20 1559.25