CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 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 12 15.00 928.50 61.90
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.00 247.00 61.75
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 22 36.50 2144.00 58.74
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 143.00 71.50 0.50
Subtotal (Total Children Is Unduplicated) 3 143.00 71.50 0.50
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Total 180.75 2261.75 12.51
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Number of Children (Unduplicated) With at Least One Service 24
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 7 10.50 699.75 0.00
T 0 0.00 0.00 0.00
26 170.25 1562.00 0.00
Other 0 0.00 0.00 0.00
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Total 33 180.75 2261.75 0.00