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:LEA
Eligibility Filter:Program Patients
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 16 26.00 1225.00 47.12
Subtotal (Total Children Is Unduplicated) 16 26.00 1225.00 47.12
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 41 194.00 5880.00 30.31
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 65.00 1950.00 30.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 3.25 220.61 67.88
Subtotal (Total Children Is Unduplicated) 58 263.50 8106.86 30.77
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Total 289.50 9331.86 32.23
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Number of Children (Unduplicated) With at Least One Service 74
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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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
136 289.50 9331.86 0.00
Other 0 0.00 0.00 0.00
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Total 136 289.50 9331.86 0.00