CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 849 421.75 15604.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 767 889.25 32902.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1083 2671.00 98790.00 36.99
Subtotal (Total Children Is Unduplicated) 1777 3982.00 147297.00 36.99
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 3 8.00 400.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 20.50 1537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 16.00 888.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.00 1050.00 75.00
Subtotal (Total Children Is Unduplicated) 22 67.00 4513.00 67.36
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 12.75 637.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.50 169.70 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 668.00 334.00 0.50
Subtotal (Total Children Is Unduplicated) 23 684.25 1191.20 1.74
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Total 4733.25 153001.20 32.32
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Number of Children (Unduplicated) With at Least One Service 1782
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Center 01
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 7 14.00 972.00 0.00
S 219 191.75 7094.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6567 4376.50 144759.95 0.00
Other 4 151.00 174.50 0.00
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Total 6797 4733.25 153001.20 0.00