CMS/EIP Fiscal Report Center: 52
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 3.25 129.50 39.85
Subtotal (Total Children Is Unduplicated) 4 3.25 129.50 39.85
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 82 119.84 8844.58 73.80
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 92 139.85 7908.10 56.55
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 24.50 2052.50 83.78
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.26 449.45 48.54
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 15.00 770.50 51.37
Subtotal (Total Children Is Unduplicated) 161 338.95 22109.63 65.23
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 258.13 12922.60 50.06
OCCT-97530-OT SESSION BY LICENSED OT 15 151.75 10570.28 69.66
PHY-97110-PT SESSION BY LICENSED PT 4 20.75 1727.71 83.26
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 242.93 17876.09 73.59
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 152.00 76.00 0.50
Subtotal (Total Children Is Unduplicated) 91 825.56 43172.68 52.30
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Total 1167.76 65411.81 56.01
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Number of Children (Unduplicated) With at Least One Service 199
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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 69 98.26 8591.82 9273.45
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 291 525.00 32051.64 0.00
T 0 0.00 0.00 0.00
221 544.50 24768.35 120.00
Other 0 0.00 0.00 0.00
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Total 581 1167.76 65411.81 9393.45