CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 259 101.50 3755.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 273 316.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 338 311.75 11534.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 400 1364.50 50477.25 36.99
Subtotal (Total Children Is Unduplicated) 612 2093.75 65767.50 31.41
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
Subtotal (Total Children Is Unduplicated) 2 4.00 272.78 68.20
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Total 2097.75 66040.28 31.48
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Number of Children (Unduplicated) With at Least One Service 612
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Center 05
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
3620 2097.75 66040.28 0.00
Other 0 0.00 0.00 0.00
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Total 3620 2097.75 66040.28 0.00