CMS/EIP Fiscal Report Center: 55
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 74 32.50 1202.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 108 126.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 121 89.50 3311.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 92 528.25 19443.50 36.81
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 170 777.25 23957.50 30.82
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 16 24.00 1200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 100.15 7511.16 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 58.18 4363.34 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 46.00 2553.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.50 562.50 75.00
Subtotal (Total Children Is Unduplicated) 86 252.83 17426.00 68.92
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.28 155.47 68.19
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 60.00 40.00 0.67
Subtotal (Total Children Is Unduplicated) 2 62.28 195.47 3.14
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Total 1092.36 41578.97 38.06
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Number of Children (Unduplicated) With at Least One Service 173
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Center 55
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 116 267.11 14660.47 14660.47
D 14 13.75 718.75 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
920 811.50 26199.75 0.00
Other 0 0.00 0.00 0.00
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Total 1050 1092.36 41578.97 14660.47