CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 293 120.50 4458.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 213 221.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 447 583.25 21571.00 36.98
TCM-T1017TL-TARGETED CASE MANAGEMENT 616 1852.25 68255.75 36.85
Subtotal (Total Children Is Unduplicated) 969 2777.00 94285.25 33.95
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Screening, Eval, and Assessment,Class #02
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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 19.50 1082.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 22.00 1650.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 33 52.00 3408.25 65.54
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 5.75 287.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 20 16.25 812.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 3.00 150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 147.00 7350.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 12.00 600.00 50.00
INTR-INTR-INTERPRETER 10 15.50 775.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 166 23853.0 20032.92 0.84
Subtotal (Total Children Is Unduplicated) 170 24055.3 30101.67 1.25
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Total 26884.25 127795.17 4.75
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Number of Children (Unduplicated) With at Least One Service 1019
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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 0 0.00 0.00 0.00
D 254 172.00 6778.00 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
4439 26712.25 121017.17 0.00
Other 0 0.00 0.00 0.00
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Total 4693 26884.25 127795.17 0.00