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
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 270 111.00 4097.75 36.92
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 263 267.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 487 556.50 20581.25 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 1150 3554.00 130443.50 36.70
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1159 4489.50 155122.50 34.55
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 19.00 1425.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 29.50 2428.13 82.31
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 18.50 1026.75 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 60.50 4931.26 81.51
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 45.00 2497.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 80.00 7115.65 88.95
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 371.50 185.75
Subtotal (Total Children Is Unduplicated) 136 256.50 20045.79 78.15
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.00 100.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 20.75 1037.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 16.00 800.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 128 656.75 34740.34 52.90
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 12.00 600.00 50.00
INTR-INTR-INTERPRETER 2 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 164 27533.0 23455.05 0.85
Subtotal (Total Children Is Unduplicated) 172 28250.3 61273.16 2.17
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Total 32996.25 236441.45 7.17
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Number of Children (Unduplicated) With at Least One Service 1173
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Center 54
Flag Claims Units Chgs Paid
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R 15 10.50 379.25 0.00
U 0 0.00 0.00 0.00
B 949 570.00 21054.00 0.00
P 1994 1337.00 53770.40 88195.72
D 18 10.25 379.25 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
5146 31068.50 160858.55 0.00
Other 0 0.00 0.00 0.00
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Total 8122 32996.25 236441.45 88195.72