CMS/EIP Fiscal Report Center: 09
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 24 18.00 666.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 55 39.75 1470.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 83 156.75 5799.75 37.00
Subtotal (Total Children Is Unduplicated) 124 217.50 7936.50 36.49
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 41.00 2967.00 72.37
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.00 787.50 71.59
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.50 845.50 62.63
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 26.50 1470.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 30 99.50 6608.25 66.41
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 605.00 302.50 0.50
Subtotal (Total Children Is Unduplicated) 13 605.00 302.50 0.50
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Total 922.00 14847.25 16.10
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Number of Children (Unduplicated) With at Least One Service 128
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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 210 527.75 9702.25 9702.25
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 93 386.75 4754.50 4754.50
4 7.50 390.50 0.00
Other 0 0.00 0.00 0.00
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Total 307 922.00 14847.25 14456.75