CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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 27 9.25 342.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 112 164.00 6058.75 36.94
TCM-T1017TL-TARGETED CASE MANAGEMENT 161 656.25 24235.00 36.93
Subtotal (Total Children Is Unduplicated) 161 830.50 30636.00 36.89
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 21.50 1612.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 35.50 2662.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 56.50 3135.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 66.50 5709.39 85.86
Subtotal (Total Children Is Unduplicated) 98 192.00 13990.89 72.87
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 88 4692.00 3982.95 0.85
Subtotal (Total Children Is Unduplicated) 88 4692.00 3982.95 0.85
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Total 5714.50 48609.84 8.51
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Number of Children (Unduplicated) With at Least One Service 164
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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 5 5.75 421.75 0.00
P 551 3671.00 20595.84 20142.54
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 0 0.00 0.00 0.00
748 2036.25 27509.00 0.00
Other 1 1.50 83.25 0.00
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Total 1305 5714.50 48609.84 20142.54