CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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 2 1.00 37.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 41.50 1535.50 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 21 46.00 1628.00 35.39
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.00 412.50 68.75
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 8.00 416.25 52.03
Subtotal (Total Children Is Unduplicated) 9 15.50 941.25 60.73
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Total 61.50 2569.25 41.78
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Number of Children (Unduplicated) With at Least One Service 28
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Center 02
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
65 61.50 2569.25 0.00
Other 0 0.00 0.00 0.00
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Total 65 61.50 2569.25 0.00