CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 53 28.75 1063.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 100.00 3700.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 105 376.00 13912.00 37.00
Subtotal (Total Children Is Unduplicated) 157 504.75 18675.75 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 40.00 3000.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 33.50 1859.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 22.00 1650.00 75.00
Subtotal (Total Children Is Unduplicated) 52 113.50 7691.00 67.76
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
INTR-INTR-INTERPRETER 1 1.50 75.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 39 1616.00 861.60 0.53
Subtotal (Total Children Is Unduplicated) 40 1622.50 1186.60 0.73
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Total 2240.75 27553.35 12.30
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Number of Children (Unduplicated) With at Least One Service 165
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Center 01
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 109 1584.00 6683.35 6683.35
D 0 0.00 0.00 0.00
S 51 48.75 1803.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
629 602.50 18702.50 0.00
Other 4 5.50 363.75 0.00
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Total 793 2240.75 27553.35 6683.35