CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:OTHER
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 2 2.00 150.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 2 4.00 300.00 75.00
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.25 50.00 200.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 195.00 97.50 0.50
Subtotal (Total Children Is Unduplicated) 2 195.25 147.50 0.76
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Total 199.25 447.50 2.25
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Number of Children (Unduplicated) With at Least One Service 2
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Center 05
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
9 199.25 447.50 0.00
Other 0 0.00 0.00 0.00
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Total 9 199.25 447.50 0.00