CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 15 7.25 268.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 28 26.50 980.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 92.00 3404.00 37.00
Subtotal (Total Children Is Unduplicated) 38 125.75 4652.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.48 216.50 48.33
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 8 12.48 738.50 59.17
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 173.00 86.50 0.50
Subtotal (Total Children Is Unduplicated) 6 173.00 86.50 0.50
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Total 311.23 5477.75 17.60
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Number of Children (Unduplicated) With at Least One Service 38
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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 0 0.00 0.00 0.00
P 15 185.48 825.00 825.00
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
211 125.75 4652.75 0.00
Other 0 0.00 0.00 0.00
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Total 226 311.23 5477.75 825.00