CMS/EIP Fiscal Report Center: 53
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 8 3.00 111.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 8 8.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 12.75 471.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 11.25 416.25 37.00
Subtotal (Total Children Is Unduplicated) 18 35.00 999.00 28.54
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 3 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 4 8.00 483.00 60.38
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.00 100.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 10.00 500.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 12.00 600.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.00 450.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 13 2381.00 1190.50 0.50
Subtotal (Total Children Is Unduplicated) 14 2416.00 2915.50 1.21
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Total 2459.00 4397.50 1.79
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Number of Children (Unduplicated) With at Least One Service 20
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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 17 811.00 862.00 862.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 15 622.00 954.50 954.50
T 0 0.00 0.00 0.00
88 1026.00 2581.00 0.00
Other 0 0.00 0.00 0.00
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Total 120 2459.00 4397.50 1816.50