CMS/EIP Fiscal Report Center: 57
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 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3 3.00 0.00 0.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.00 166.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 7.00 388.50 55.50
Subtotal (Total Children Is Unduplicated) 11 16.50 1042.50 63.18
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 3 12.00 814.56 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 5 14.00 895.64 63.97
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Total 33.50 1938.14 57.85
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Number of Children (Unduplicated) With at Least One Service 14
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Center 57
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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
30 33.50 1938.14 0.00
Other 0 0.00 0.00 0.00
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Total 30 33.50 1938.14 0.00