CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 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 34 17.25 638.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 7 7.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 27 25.75 952.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 72 205.00 7585.00 37.00
Subtotal (Total Children Is Unduplicated) 103 255.00 9176.00 35.98
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 2 5.00 375.00 75.00
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 2.00 117.00 58.50
TRAN-TRAN-FAMILY TRANSPORTATION 1 1.00 10.80 10.80
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 130.00 65.00 0.50
Subtotal (Total Children Is Unduplicated) 2 133.00 192.80 1.45
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Total 393.00 9743.80 24.79
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Number of Children (Unduplicated) With at Least One Service 103
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Center 06
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 113 212.25 3241.05 3241.05
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
269 180.75 6502.75 0.00
Other 0 0.00 0.00 0.00
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Total 382 393.00 9743.80 3241.05