CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 12 5.50 203.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 18.50 684.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 174.50 6456.50 37.00
Subtotal (Total Children Is Unduplicated) 32 198.50 7344.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.20 600.00 42.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 15.00 832.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 16 35.70 1900.50 53.24
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 14 517.00 258.50 0.50
Subtotal (Total Children Is Unduplicated) 14 517.00 258.50 0.50
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Total 751.20 9503.50 12.65
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Number of Children (Unduplicated) With at Least One Service 32
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Center 05
Flag Claims Units Chgs Paid
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R 16 13.75 508.75 0.00
U 0 0.00 0.00 0.00
B 28 18.75 693.75 0.00
P 10 192.50 751.75 751.75
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
302 526.20 7549.25 0.00
Other 0 0.00 0.00 0.00
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Total 356 751.20 9503.50 751.75