CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 48.50 2691.75 55.50
Subtotal (Total Children Is Unduplicated) 25 48.50 2691.75 55.50
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.50 325.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 8.75 593.95 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 225.00 112.50 0.50
Subtotal (Total Children Is Unduplicated) 6 240.50 1043.95 4.34
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Total 289.00 3735.70 12.93
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Number of Children (Unduplicated) With at Least One Service 31
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Center 07
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
32 289.00 3735.70 0.00
Other 0 0.00 0.00 0.00
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Total 32 289.00 3735.70 0.00