CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Eligibility Filter:Not Part C
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 7 4.00 148.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 13.50 499.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 99.75 3681.50 36.91
Subtotal (Total Children Is Unduplicated) 26 117.25 4329.00 36.92
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.00 499.50 55.50
Subtotal (Total Children Is Unduplicated) 11 17.50 1107.75 63.30
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 195.00 97.50 0.50
Subtotal (Total Children Is Unduplicated) 5 195.00 97.50 0.50
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Total 329.75 5534.25 16.78
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Number of Children (Unduplicated) With at Least One Service 26
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Center 05
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 66 44.75 1655.75 0.00
P 13 205.00 711.00 711.00
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
113 80.00 3167.50 0.00
Other 0 0.00 0.00 0.00
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Total 192 329.75 5534.25 711.00