CMS/EIP Fiscal Report Center: 54
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 3 1.00 37.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 4 4.75 101.75 21.42
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 636.00 487.80 0.77
Subtotal (Total Children Is Unduplicated) 4 636.25 500.30 0.79
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Total 641.00 602.05 0.94
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Number of Children (Unduplicated) With at Least One Service 5
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Center 54
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 6 352.25 258.90 258.90
D 3 0.75 27.75 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
10 288.00 315.40 0.00
Other 0 0.00 0.00 0.00
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Total 19 641.00 602.05 258.90