CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 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 2 2.00 83.25 41.63
Subtotal (Total Children Is Unduplicated) 2 2.00 83.25 41.63
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Screening, Eval, and Assessment,Class #02
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 26 36.34 2778.18 76.45
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 50.35 2780.10 55.22
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.00 782.50 86.94
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 4.00 145.50 36.38
Subtotal (Total Children Is Unduplicated) 55 110.69 7181.78 64.88
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 83.70 4192.65 50.09
OCCT-97530-OT SESSION BY LICENSED OT 7 51.50 3739.86 72.62
PHY-97110-PT SESSION BY LICENSED PT 1 6.75 777.39 115.17
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 110.95 7851.72 70.77
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 45.00 22.50 0.50
Subtotal (Total Children Is Unduplicated) 52 297.90 16584.12 55.67
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Total 410.59 23849.15 58.09
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Number of Children (Unduplicated) With at Least One Service 94
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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 21 31.09 3060.10 3060.10
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 88 163.25 10173.02 0.00
T 0 0.00 0.00 0.00
106 216.25 10616.03 0.00
Other 0 0.00 0.00 0.00
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Total 215 410.59 23849.15 3060.10