CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 32.50 2437.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 23 33.50 2512.50 75.00
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 1.50 101.82 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 15 547.00 273.50 0.50
Subtotal (Total Children Is Unduplicated) 18 550.75 1487.82 2.70
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Total 584.25 4000.32 6.85
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Number of Children (Unduplicated) With at Least One Service 40
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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
45 584.25 4000.32 0.00
Other 0 0.00 0.00 0.00
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Total 45 584.25 4000.32 0.00