CMS/EIP Fiscal Report Center: 57
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 7 7.50 277.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 32 33.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 9.50 351.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 13 46.75 1729.75 37.00
Subtotal (Total Children Is Unduplicated) 38 96.75 2358.75 24.38
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 3.50 175.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 25.50 1415.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 23 56.00 3586.00 64.04
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Total 152.75 5944.75 38.92
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Number of Children (Unduplicated) With at Least One Service 38
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Center 57
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 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
124 152.75 5944.75 0.00
Other 0 0.00 0.00 0.00
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Total 124 152.75 5944.75 0.00