CMS/EIP Fiscal Report Center: 05
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 12 5.50 203.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 18.50 684.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 103.25 3820.25 37.00
Subtotal (Total Children Is Unduplicated) 31 127.25 4708.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 7.50 249.44 33.26
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
Subtotal (Total Children Is Unduplicated) 11 24.00 1272.44 53.02
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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 668.25 6239.19 9.34
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Number of Children (Unduplicated) With at Least One Service 31
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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 8 189.50 585.25 585.25
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
220 478.75 5653.94 0.00
Other 0 0.00 0.00 0.00
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Total 228 668.25 6239.19 585.25