CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.00 74.00 37.00
Subtotal (Total Children Is Unduplicated) 1 2.00 74.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.50 175.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 17.50 971.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.00 1350.00 75.00
Subtotal (Total Children Is Unduplicated) 33 68.50 4621.00 67.46
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.50 75.00 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 10.00 500.00 50.00
Subtotal (Total Children Is Unduplicated) 6 13.00 650.00 50.00
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Total 83.50 5345.00 64.01
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Number of Children (Unduplicated) With at Least One Service 39
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 25 37.00 2392.50 0.00
T 0 0.00 0.00 0.00
9 11.00 655.75 0.00
Other 26 35.50 2296.75 0.00
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Total 60 83.50 5345.00 0.00