CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
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 9 6.50 240.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 10.50 388.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 100.00 3700.00 37.00
Subtotal (Total Children Is Unduplicated) 14 117.00 4329.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 3.00 150.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 7 12.50 783.00 62.64
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 2.25 112.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 28.00 1400.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 2 38.50 2596.41 67.44
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 63.00 4276.44 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 5324.00 3383.50 0.64
Subtotal (Total Children Is Unduplicated) 8 5455.75 11768.85 2.16
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Total 5585.25 16880.85 3.02
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Number of Children (Unduplicated) With at Least One Service 14
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Center 51
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 87 58.00 2184.00 0.00
P 89 5393.25 7626.99 7626.99
D 10 6.25 231.25 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
132 127.75 6838.61 0.00
Other 0 0.00 0.00 0.00
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Total 318 5585.25 16880.85 7626.99