CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 37 16.50 610.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 68 56.25 2081.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 122.50 4523.25 36.92
Subtotal (Total Children Is Unduplicated) 87 195.25 7215.00 36.95
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Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 7.00 350.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.50 712.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.67 50.00 74.63
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 125.00 41.67
Subtotal (Total Children Is Unduplicated) 17 25.67 1572.00 61.24
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 58 2859.00 1429.50 0.50
Subtotal (Total Children Is Unduplicated) 58 2859.00 1429.50 0.50
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Total 3079.92 10216.50 3.32
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Number of Children (Unduplicated) With at Least One Service 92
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Center 52
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 12 184.67 513.50 513.50
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
417 2895.25 9703.00 0.00
Other 0 0.00 0.00 0.00
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Total 429 3079.92 10216.50 513.50