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:Program Patients
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 3 1.75 64.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 3.50 129.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 174.50 6382.50 36.58
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 46 183.75 6576.75 35.79
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 10.00 750.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.00 862.50 71.88
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 13.00 693.75 53.37
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 22 39.50 2617.25 66.26
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 3 3.00 150.00 50.00
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Total 226.25 9344.00 41.30
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Number of Children (Unduplicated) With at Least One Service 63
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Center 02
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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
265 226.25 9344.00 0.00
Other 0 0.00 0.00 0.00
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Total 265 226.25 9344.00 0.00