CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EXT
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 1 -2.00 -150.00 0.00
Subtotal (Total Children Is Unduplicated) 1 -2.00 -150.00 75.00
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 -5.00 -131.46 0.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 117.00 58.50 0.50
Subtotal (Total Children Is Unduplicated) 2 112.00 -72.96 -0.65
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Total 110.00 -222.96 -2.03
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Number of Children (Unduplicated) With at Least One Service 3
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Center 07
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 1 -2.00 -150.00 -150.00
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
2 112.00 -72.96 0.00
Other 0 0.00 0.00 0.00
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Total 3 110.00 -222.96 -150.00