CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 15.00 555.00 37.00
Subtotal (Total Children Is Unduplicated) 11 15.00 555.00 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 656.26 262.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 15.50 1378.13 88.91
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 10.50 787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 21.50 2437.52 113.37
Subtotal (Total Children Is Unduplicated) 34 52.00 5370.41 103.28
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 85.00 4842.25 56.97
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 50.00 42.50 0.85
Subtotal (Total Children Is Unduplicated) 20 136.00 4934.75 36.28
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Total 203.00 10860.16 53.50
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Number of Children (Unduplicated) With at Least One Service 59
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Center 54
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 32 35.50 4139.16 1681.19
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
114 167.50 6721.00 0.00
Other 0 0.00 0.00 0.00
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Total 146 203.00 10860.16 1681.19