CMS/EIP Fiscal Report Center: 55
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
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 13.75 508.75 37.00
Subtotal (Total Children Is Unduplicated) 7 14.75 508.75 34.49
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.00 112.50 56.25
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.53 39.92 75.32
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
Subtotal (Total Children Is Unduplicated) 8 11.53 827.42 71.76
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Total 26.28 1336.17 50.84
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Number of Children (Unduplicated) With at Least One Service 15
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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
20 26.28 1336.17 0.00
Other 0 0.00 0.00 0.00
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Total 20 26.28 1336.17 0.00