CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
Subtotal (Total Children Is Unduplicated) 1 3.50 233.25 66.64
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.50 169.70 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 48.00 24.00 0.50
Subtotal (Total Children Is Unduplicated) 4 57.50 543.70 9.46
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Total 61.00 776.95 12.74
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Number of Children (Unduplicated) With at Least One Service 4
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Center 03
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
15 61.00 776.95 0.00
Other 0 0.00 0.00 0.00
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Total 15 61.00 776.95 0.00