CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 111 115.250000 4264.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 95 53.250000 1970.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 267.500000 9897.5000 37.0000
Subtotal (Total Children Is Unduplicated) 170 437.000000 16132.0000 36.9153
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7 24.500000 1577.2500 64.3776
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EI Services,Class #03
INTR-INTR-INTERPRETER 46 86.750000 4337.5000 50.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 10 780.000000 390.0000 0.5000
Subtotal (Total Children Is Unduplicated) 54 866.750000 4727.5000 5.4543
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Total 1328.250000 22436.7500 16.8920
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Number of Children (Unduplicated) With at Least One Service 184
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Center 09
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 541 1322.750000 22207.2500 22207.2500
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
5 5.500000 229.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 546 1328.250000 22436.7500 22207.2500