CMS/EIP Fiscal Report Center: 54
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.50 18.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 262.50 43.75
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 7.00 268.25 38.32
TCM-T1017TL-TARGETED CASE MANAGEMENT 66 151.00 5747.75 38.06
Subtotal (Total Children Is Unduplicated) 70 164.50 6297.00 38.28
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 235.80 235.80
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 11.50 1387.50 120.65
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 29.00 4678.13 161.31
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 48.50 4781.26 98.58
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.50 305.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 129.50 21253.15 164.12
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 849.80 283.27
Subtotal (Total Children Is Unduplicated) 137 230.50 33629.64 145.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 187.50 21345.24 113.84
OCCT-97530-OT SESSION BY LICENSED OT 4 16.00 3586.64 224.17
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 77.00 77.00 1.00
Subtotal (Total Children Is Unduplicated) 30 280.50 25008.88 89.16
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Total 675.50 64935.52 96.13
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Number of Children (Unduplicated) With at Least One Service 199
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Center 54
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 80 100.00 21669.00 11565.53
D 0 0.00 0.00 0.00
S 1 1.00 235.80 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
490 574.50 43030.72 129.94
Other 0 0.00 0.00 0.00
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Total 571 675.50 64935.52 11695.47