CMS/EIP Fiscal Report Center: 55
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 2.25 83.25 37.00
Subtotal (Total Children Is Unduplicated) 2 2.25 83.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 22.50 1825.00 81.11
Subtotal (Total Children Is Unduplicated) 15 22.50 1825.00 81.11
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Total 24.75 1908.25 77.10
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Number of Children (Unduplicated) With at Least One Service 16
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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 1 1.50 250.00 0.00
T 0 0.00 0.00 0.00
16 23.25 1658.25 0.00
Other 0 0.00 0.00 0.00
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Total 17 24.75 1908.25 0.00