CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 17 9.25 342.25 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 44.00 1628.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 35.75 1322.75 37.00
Subtotal (Total Children Is Unduplicated) 29 89.00 3293.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.50 525.00 70.00
Subtotal (Total Children Is Unduplicated) 8 24.00 1655.25 68.97
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 20 1859.00 929.50 0.50
Subtotal (Total Children Is Unduplicated) 20 1859.00 929.50 0.50
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Total 1972.00 5877.75 2.98
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Number of Children (Unduplicated) With at Least One Service 31
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Center 02
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 0 0.00 0.00 0.00
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 27 1143.50 1397.25 1397.25
106 828.50 4480.50 0.00
Other 0 0.00 0.00 0.00
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Total 133 1972.00 5877.75 1397.25