CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 64 43.75 1618.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 106 106.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 140 667.75 24706.75 37.00
Subtotal (Total Children Is Unduplicated) 140 817.50 26325.50 32.20
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 20.50 1537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 19.00 1425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 63.50 3524.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 42.50 3187.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.00 5365.00 185.00
Subtotal (Total Children Is Unduplicated) 106 186.50 15802.75 84.73
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 7.50 509.10 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.00 271.52 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 80 81.00 648.00 8.00
Subtotal (Total Children Is Unduplicated) 81 92.50 1428.62 15.44
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Total 1096.50 43556.87 39.72
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Number of Children (Unduplicated) With at Least One Service 141
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Center 04
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 193 239.50 11158.50 0.00
P 187 258.75 10499.25 10511.01
D 3 2.00 74.00 74.00
S 0 0.00 0.00 0.00
H 4 11.50 780.62 780.62
T 0 0.00 0.00 0.00
538 584.75 21044.50 0.00
Other 0 0.00 0.00 0.00
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Total 925 1096.50 43556.87 11365.63