CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 2 0.50 18.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.50 166.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 27.25 1008.25 37.00
Subtotal (Total Children Is Unduplicated) 19 32.25 1193.25 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 7.50 375.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 3 8.00 400.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 19.50 1462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 31.00 1692.75 54.60
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 28.00 2100.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 2.00 114.54 57.27
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 3.00 150.45 50.15
Subtotal (Total Children Is Unduplicated) 49 114.50 7340.74 64.11
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 15.00 750.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 4.00 2.00 0.50
Subtotal (Total Children Is Unduplicated) 9 27.00 1152.00 42.67
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Total 173.75 9685.99 55.75
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Number of Children (Unduplicated) With at Least One Service 75
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Center 01
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 93 121.00 7290.25 0.00
S 19 24.75 915.75 0.00
H 12 19.50 1152.49 0.00
T 0 0.00 0.00 0.00
9 8.50 327.50 0.00
Other 0 0.00 0.00 0.00
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Total 133 173.75 9685.99 0.00