CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1 1.00 55.50 55.50
Subtotal (Total Children Is Unduplicated) 1 1.00 55.50 55.50
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.50 75.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 2.50 130.50 52.20
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2
----------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
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
2 2.50 130.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 2.50 130.50 0.00