CMS/EIP Fiscal Report Center: 51
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 21 14.50 536.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 30 33.50 1239.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 117.75 4356.75 37.00
Subtotal (Total Children Is Unduplicated) 46 165.75 6132.75 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.50 450.00 69.23
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.00 300.00 60.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 12.50 900.00 72.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 81.00 40.50
Subtotal (Total Children Is Unduplicated) 17 33.00 2256.00 68.36
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 27 1236.00 618.00 0.50
Subtotal (Total Children Is Unduplicated) 27 1236.00 618.00 0.50
----------------------------------------------------------------------------------------------------------------
Total 1434.75 9006.75 6.28
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 51
----------------------------------------------------------------------------------------------------------------
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
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 64 1261.00 2343.00 2343.00
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 0 0.00 0.00 0.00
202 173.75 6663.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 266 1434.75 9006.75 2343.00