CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 7 4.00 148.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 26 41.25 1526.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 216.75 8019.75 37.00
Subtotal (Total Children Is Unduplicated) 85 262.00 9694.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 10.00 500.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 17.50 1312.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 30.00 2250.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 64.50 4837.50 75.00
Subtotal (Total Children Is Unduplicated) 86 176.50 12012.50 68.06
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.50 175.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 5.50 275.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.50 75.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 20.00 1000.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 180.00 60.00
Subtotal (Total Children Is Unduplicated) 12 33.50 1705.00 50.90
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Total 472.00 23411.50 49.60
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Number of Children (Unduplicated) With at Least One Service 175
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Center 01
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 0 0.00 0.00 0.00
P 22 27.50 1846.50 2524.62
D 11 16.50 1120.50 0.00
S 94 104.00 3848.00 0.00
H 54 75.75 4722.00 0.00
T 33 47.00 3041.00 3041.00
166 164.25 6461.75 0.00
Other 27 37.00 2371.75 0.00
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Total 407 472.00 23411.50 5565.62