CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 1 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 5.50 203.50 37.00
Subtotal (Total Children Is Unduplicated) 1 6.00 222.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.50 487.50 75.00
Subtotal (Total Children Is Unduplicated) 3 10.00 681.75 68.18
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 1 30.00 15.00 0.50
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Total 46.00 918.75 19.97
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Number of Children (Unduplicated) With at Least One Service 3
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Center 07
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 0 0.00 0.00 0.00
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
17 46.00 918.75 0.00
Other 0 0.00 0.00 0.00
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Total 17 46.00 918.75 0.00