CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 46 35.00 1295.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 13 13.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 48 101.25 3746.25 37.00
Subtotal (Total Children Is Unduplicated) 79 149.25 5041.25 33.78
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 7.00 350.00 50.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 2.00 150.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
Subtotal (Total Children Is Unduplicated) 14 12.00 835.00 69.58
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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 3 312.00 156.00 0.50
Subtotal (Total Children Is Unduplicated) 9 319.00 212.00 0.66
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Total 480.25 6088.25 12.68
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Number of Children (Unduplicated) With at Least One Service 79
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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 6 312.00 156.00 156.00
D 14 8.50 314.50 314.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
341 159.75 5617.75 0.00
Other 0 0.00 0.00 0.00
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Total 361 480.25 6088.25 470.50