CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 39 31.00 1147.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 52 130.75 4837.75 37.00
Subtotal (Total Children Is Unduplicated) 82 171.75 5984.75 34.85
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 4.50 225.00 50.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 7 6.00 337.50 56.25
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 7 7.00 56.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 442.00 221.00 0.50
Subtotal (Total Children Is Unduplicated) 10 449.00 277.00 0.62
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Total 626.75 6599.25 10.53
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Number of Children (Unduplicated) With at Least One Service 85
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Center 04
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 9 442.00 221.00 221.00
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
378 184.75 6378.25 0.00
Other 0 0.00 0.00 0.00
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Total 387 626.75 6599.25 221.00