CMS/EIP Fiscal Report Center: 54
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 5.75 212.75 37.00
Subtotal (Total Children Is Unduplicated) 3 5.75 212.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.50 815.63 108.75
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 19.00 2831.28 149.01
Subtotal (Total Children Is Unduplicated) 23 32.00 4059.41 126.86
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EI Services,Class #03
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 103.50 5527.46 53.41
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 15.00 12.75 0.85
Subtotal (Total Children Is Unduplicated) 24 119.50 5565.21 46.57
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Total 157.25 9837.37 62.56
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Number of Children (Unduplicated) With at Least One Service 46
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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 22 23.00 3374.37 1768.80
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
119 134.25 6463.00 0.00
Other 0 0.00 0.00 0.00
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Total 141 157.25 9837.37 1768.80