CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 3 0.75 27.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.25 157.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 7.25 268.25 37.00
Subtotal (Total Children Is Unduplicated) 9 17.25 453.25 26.28
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.25 152.73 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 146.00 124.10 0.85
Subtotal (Total Children Is Unduplicated) 3 148.50 289.33 1.95
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Total 165.75 742.58 4.48
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Number of Children (Unduplicated) With at Least One Service 9
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Center 54
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 6 108.50 255.33 255.33
D 6 3.75 138.75 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
19 53.50 348.50 0.00
Other 0 0.00 0.00 0.00
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Total 31 165.75 742.58 255.33