CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 47 30.50 1128.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 114 86.00 3182.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 94 227.00 8399.00 37.00
Subtotal (Total Children Is Unduplicated) 169 348.50 12709.50 36.47
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 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 33 48.00 3600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 21.50 1612.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 24.00 1755.00 73.13
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 37.50 2081.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.00 450.00 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 53 152.50 10468.00 68.64
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 0.25 12.50 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 41 2310.00 1155.00 0.50
Subtotal (Total Children Is Unduplicated) 41 2310.25 1167.50 0.51
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Total 2811.25 24345.00 8.66
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Number of Children (Unduplicated) With at Least One Service 174
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Center 09
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 345 1487.75 16322.25 16322.25
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 194 1157.50 7903.25 7903.25
8 166.00 119.50 0.00
Other 0 0.00 0.00 0.00
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Total 547 2811.25 24345.00 24225.50