CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 30.000000 1110.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 30.000000 1110.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 270.6600 135.3300
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 270.6600 135.3300
Subtotal (Total Children Is Unduplicated) 1 4.000000 541.3200 135.3300
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Total 34.000000 1651.3200 48.5682
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Number of Children (Unduplicated) With at Least One Service 2
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 34.000000 1651.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3 34.000000 1651.3200 0.0000