CMS/EIP Fiscal Report Center: 55
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 8.00 296.00 37.00
Subtotal (Total Children Is Unduplicated) 5 9.00 296.00 32.89
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 23 34.00 1750.00 51.47
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 3 6.00 450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 69.00 5587.50 80.98
Subtotal (Total Children Is Unduplicated) 73 119.50 8458.00 70.78
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.75 50.91 67.88
Subtotal (Total Children Is Unduplicated) 1 0.75 50.91 67.88
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Total 129.25 8804.91 68.12
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Number of Children (Unduplicated) With at Least One Service 77
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Center 55
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 5 7.50 500.00 364.78
D 4 5.50 350.00 0.00
S 0 0.00 0.00 0.00
H 10 15.00 1368.00 0.00
T 0 0.00 0.00 0.00
68 101.25 6586.91 0.00
Other 0 0.00 0.00 0.00
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Total 87 129.25 8804.91 364.78