CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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
CASE-CASE-NON-TCM CASE MANAGEMENT 81 54.00 1998.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 27.00 999.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 145 366.50 13560.50 37.00
Subtotal (Total Children Is Unduplicated) 207 448.50 16557.50 36.92
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.50 487.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 17 24.00 1679.00 69.96
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 39.00 1950.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 12.50 848.50 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 21 6027.00 3097.20 0.51
Subtotal (Total Children Is Unduplicated) 22 6082.50 6113.58 1.01
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Total 6555.00 24350.08 3.71
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Number of Children (Unduplicated) With at Least One Service 216
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Center 01
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 140 5189.50 5636.68 5636.68
D 18 17.50 913.50 0.00
S 523 353.25 10040.75 41.50
H 0 0.00 0.00 0.00
T 32 689.00 1334.30 1334.30
403 302.75 6423.35 0.00
Other 2 3.00 1.50 0.00
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Total 1118 6555.00 24350.08 7012.48