CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 42 31.25 1156.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 65 55.25 2044.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 143.25 5300.25 37.00
Subtotal (Total Children Is Unduplicated) 111 229.75 8500.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 27.00 2025.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 23.50 1304.25 55.50
Subtotal (Total Children Is Unduplicated) 23 76.00 5241.75 68.97
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 9 541.00 270.50 0.50
Subtotal (Total Children Is Unduplicated) 9 541.00 270.50 0.50
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Total 846.75 14013.00 16.55
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Number of Children (Unduplicated) With at Least One Service 117
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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 166 618.50 8039.75 8039.75
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 148 226.00 5890.00 5890.00
3 2.25 83.25 0.00
Other 0 0.00 0.00 0.00
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Total 317 846.75 14013.00 13929.75