CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.00 148.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.00 37.00 37.00
Subtotal (Total Children Is Unduplicated) 7 8.00 185.00 23.13
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
Subtotal (Total Children Is Unduplicated) 2 2.00 130.50 65.25
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.25 31.25 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 6.50 441.22 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 3.00 203.64 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.00 271.52 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 893.00 759.05 0.85
Subtotal (Total Children Is Unduplicated) 6 908.75 1756.68 1.93
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Total 918.75 2072.18 2.26
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Number of Children (Unduplicated) With at Least One Service 10
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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 14 858.50 1763.43 1763.43
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
15 60.25 308.75 0.00
Other 0 0.00 0.00 0.00
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Total 29 918.75 2072.18 1763.43