CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 2.75 101.75 37.00
Subtotal (Total Children Is Unduplicated) 2 2.75 101.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 250.00 250.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 10.00 1975.00 197.50
Subtotal (Total Children Is Unduplicated) 12 12.00 2300.00 191.67
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Total 14.75 2401.75 162.83
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Number of Children (Unduplicated) With at Least One Service 14
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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 9 9.00 2075.00 0.00
T 0 0.00 0.00 0.00
5 5.75 326.75 0.00
Other 0 0.00 0.00 0.00
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Total 14 14.75 2401.75 0.00