CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 11 5.75 212.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 38.50 1424.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 180.75 6687.75 37.00
Subtotal (Total Children Is Unduplicated) 39 225.00 8325.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.00 450.00 56.25
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.50 638.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.50 337.50 75.00
Subtotal (Total Children Is Unduplicated) 15 32.00 1996.50 62.39
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 8 270.00 135.00 0.50
Subtotal (Total Children Is Unduplicated) 8 270.00 135.00 0.50
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Total 527.00 10456.50 19.84
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Number of Children (Unduplicated) With at Least One Service 40
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Center 05
Flag Claims Units Chgs Paid
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R 20 13.25 490.25 0.00
U 0 0.00 0.00 0.00
B 123 95.50 3533.50 0.00
P 5 93.49 240.51 240.51
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
186 324.76 6192.24 0.00
Other 0 0.00 0.00 0.00
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Total 334 527.00 10456.50 240.51