CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.250000 83.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2 2.750000 101.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 4 5.000000 256.5000 51.3000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 10.000000 500.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 67.8800 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 74.000000 37.0000 0.5000
Subtotal (Total Children Is Unduplicated) 7 86.000000 629.8800 7.3242
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Total 93.750000 988.1300 10.5401
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Number of Children (Unduplicated) With at Least One Service 12
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 59.000000 760.3800 0.0000
Other 4 34.750000 227.7500 0.0000
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Total 20 93.750000 988.1300 0.0000