CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.00 1217.50 67.64
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.50 306.50 55.73
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 20.50 1137.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 24 51.50 3149.25 61.15
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 20.00 10.00 0.50
Subtotal (Total Children Is Unduplicated) 1 20.00 10.00 0.50
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Total 71.50 3159.25 44.19
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Number of Children (Unduplicated) With at Least One Service 24
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Center 52
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 19 27.50 1743.75 0.00
T 0 0.00 0.00 0.00
21 44.00 1415.50 0.00
Other 0 0.00 0.00 0.00
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Total 40 71.50 3159.25 0.00