CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 16 11.00 407.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 49.00 1766.75 36.06
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 36.00 1332.00 37.00
Subtotal (Total Children Is Unduplicated) 28 96.00 3505.75 36.52
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.50 1047.50 72.24
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.00 555.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 11 33.50 2227.50 66.49
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EI Services,Class #03
INTR-INTR-INTERPRETER 1 4.00 200.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 1791.00 895.50 0.50
Subtotal (Total Children Is Unduplicated) 18 1795.00 1095.50 0.61
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Total 1924.50 6828.75 3.55
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Number of Children (Unduplicated) With at Least One Service 29
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Center 02
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 36 1261.50 2260.00 2260.00
117 663.00 4568.75 0.00
Other 0 0.00 0.00 0.00
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Total 153 1924.50 6828.75 2260.00