CMS/EIP Fiscal Report Center: 10
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.75 64.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 6.00 222.00 37.00
Subtotal (Total Children Is Unduplicated) 3 9.75 286.75 29.41
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 1 1.50 101.82 67.88
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Total 11.25 388.57 34.54
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Number of Children (Unduplicated) With at Least One Service 3
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Center 10
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 1 1.50 101.82 101.82
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
13 9.75 286.75 0.00
Other 0 0.00 0.00 0.00
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Total 14 11.25 388.57 101.82