CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Not Part C
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 38 19.00 703.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 72 69.75 2580.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 52 336.00 12432.00 37.00
Subtotal (Total Children Is Unduplicated) 83 426.75 15715.75 36.83
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 8 9.50 527.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 13.44 703.04 52.31
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.00 300.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 40.00 2220.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 41 72.44 4123.79 56.93
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.50 25.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 10.00 500.00 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.32 446.70 53.69
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 37 1560.00 780.00 0.50
Subtotal (Total Children Is Unduplicated) 38 1581.82 1901.70 1.20
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Total 2081.01 21741.24 10.45
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Number of Children (Unduplicated) With at Least One Service 85
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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 117 1653.26 5950.49 5950.49
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
649 427.75 15790.75 0.00
Other 0 0.00 0.00 0.00
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Total 766 2081.01 21741.24 5950.49