CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 25.50 943.50 37.00
Subtotal (Total Children Is Unduplicated) 8 26.25 971.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 6 6.50 412.25 63.42
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 2 2.00 100.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 34.75 1483.50 42.69
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 13
----------------------------------------------------------------------------------------------------------------
Center 02
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
34 34.75 1483.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 34 34.75 1483.50 0.00