CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 21 32.25 1193.25 37.00
Subtotal (Total Children Is Unduplicated) 21 32.50 1202.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 36.00 1998.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.00 1725.00 75.00
Subtotal (Total Children Is Unduplicated) 41 131.50 9063.00 68.92
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 4 12.50 625.00 50.00
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Total 176.50 10890.50 61.70
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Number of Children (Unduplicated) With at Least One Service 65
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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 79 131.00 8713.00 0.00
S 1 0.50 18.50 0.00
H 2 3.50 262.50 0.00
T 0 0.00 0.00 0.00
46 32.00 1184.00 0.00
Other 7 9.50 712.50 0.00
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Total 135 176.50 10890.50 0.00