CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 1030 823.25 30460.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 390 405.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 564 821.75 30404.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 868 2374.75 87847.25 36.99
TCON-TCON-TRANSITION CONFERENCE 44 44.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1482 4468.75 148712.25 33.28
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 9 20.00 1000.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 10.50 787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 73.50 4079.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 211.50 15712.50 74.29
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 1.50 75.00 50.00
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 0.25 12.50 50.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 21 22.00 1100.00 50.00
Subtotal (Total Children Is Unduplicated) 119 346.75 23252.12 67.06
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 8.50 425.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 85 4786.00 2393.00 0.50
Subtotal (Total Children Is Unduplicated) 105 4794.50 2818.00 0.59
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Total 9610.00 174782.37 18.19
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Number of Children (Unduplicated) With at Least One Service 1484
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Center 07
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 11 5.25 194.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8363 9604.75 174588.12 0.00
Other 0 0.00 0.00 0.00
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Total 8374 9610.00 174782.37 0.00