CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 1.000000 37.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 12.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 8.000000 296.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 12 25.250000 490.2500 19.4158
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Screening, Eval, and Assessment,Class #02
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 1.000000 48.5000 48.5000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 68.000000 1700.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.000000 750.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 203.6400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 14 2775.000000 1387.5000 0.5000
Subtotal (Total Children Is Unduplicated) 14 2866.500000 4316.1400 1.5057
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Total 2892.750000 4854.8900 1.6783
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Number of Children (Unduplicated) With at Least One Service 15
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 34 1044.000000 1459.5000 1459.5000
T 28 846.250000 859.0100 859.0100
57 1002.500000 2536.3800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 119 2892.750000 4854.8900 2318.5100