CMS/EIP Fiscal Report Center: 54
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 56.50 2025.75 35.85
Subtotal (Total Children Is Unduplicated) 21 59.00 2118.25 35.90
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.50 1078.13 93.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 32.50 2831.26 87.12
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 25.50 3028.15 118.75
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 323.00 323.00
Subtotal (Total Children Is Unduplicated) 44 82.00 8025.54 97.87
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 65.00 5152.84 79.27
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 19 69.00 5424.36 78.61
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Total 210.00 15568.15 74.13
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Number of Children (Unduplicated) With at Least One Service 76
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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 20 32.00 5872.40 3043.64
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
168 178.00 9695.75 0.00
Other 0 0.00 0.00 0.00
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Total 188 210.00 15568.15 3043.64