CMS/EIP Fiscal Report Center: 52
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.25 46.25 37.00
Subtotal (Total Children Is Unduplicated) 1 1.25 46.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 43.80 2882.00 65.80
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 16.50 1097.50 66.52
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 40.00 2290.50 57.26
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.50 562.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 66 121.80 7550.00 61.99
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 260.00 130.00 0.50
Subtotal (Total Children Is Unduplicated) 5 260.00 130.00 0.50
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Total 383.05 7726.25 20.17
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Number of Children (Unduplicated) With at Least One Service 69
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Center 52
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 7 8.50 547.75 458.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 48 64.50 4166.50 0.00
T 0 0.00 0.00 0.00
49 310.05 3012.00 120.00
Other 0 0.00 0.00 0.00
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Total 104 383.05 7726.25 578.50