CMS/EIP Fiscal Report Center: 55
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 3.00 101.75 33.92
Subtotal (Total Children Is Unduplicated) 3 3.25 111.00 34.15
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 6 11.00 675.00 61.36
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.00 1050.00 75.00
Subtotal (Total Children Is Unduplicated) 17 28.00 1912.50 68.30
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Total 31.25 2023.50 64.75
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Number of Children (Unduplicated) With at Least One Service 20
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Center 55
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
22 31.25 2023.50 0.00
Other 0 0.00 0.00 0.00
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Total 22 31.25 2023.50 0.00