CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 8 3.00 111.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 3.75 138.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 11 10.50 277.50 26.43
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 1 2.00 111.00 55.50
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
INTR-INTR-INTERPRETER 2 3.00 150.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 300.00 150.00 0.50
Subtotal (Total Children Is Unduplicated) 4 305.00 400.00 1.31
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Total 317.50 788.50 2.48
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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 0.00 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 3 60.50 48.50 48.50
31 257.00 740.00 0.00
Other 0 0.00 0.00 0.00
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Total 34 317.50 788.50 48.50