CMS/EIP Fiscal Report Center: 52
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 27 11.25 416.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 44 32.75 1211.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 115.50 4266.25 36.94
Subtotal (Total Children Is Unduplicated) 58 160.50 5894.25 36.72
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.50 200.00 44.44
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.84 1160.79 68.93
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 123.50 41.17
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 14 31.84 1924.29 60.44
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 28 1238.00 619.00 0.50
Subtotal (Total Children Is Unduplicated) 28 1238.00 619.00 0.50
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Total 1430.34 8437.54 5.90
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Number of Children (Unduplicated) With at Least One Service 59
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Center 52
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 5 46.00 271.00 271.00
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 0 0.00 0.00 0.00
282 1384.34 8166.54 0.00
Other 0 0.00 0.00 0.00
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Total 287 1430.34 8437.54 271.00