CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 11 5.75 212.75 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 38.50 1424.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 65.75 2432.75 37.00
Subtotal (Total Children Is Unduplicated) 35 110.00 4070.00 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 1 0.99 37.26 37.64
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 5 8.49 492.51 58.01
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 240.00 120.00 0.50
Subtotal (Total Children Is Unduplicated) 7 240.00 120.00 0.50
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Total 358.49 4682.51 13.06
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Number of Children (Unduplicated) With at Least One Service 36
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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 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
162 265.00 4442.00 0.00
Other 0 0.00 0.00 0.00
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Total 167 358.49 4682.51 240.51