CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 5.00 277.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 17.00 943.50 55.50
Subtotal (Total Children Is Unduplicated) 13 22.00 1221.00 55.50
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Total 22.00 1221.00 55.50
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Number of Children (Unduplicated) With at Least One Service 13
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Center 09
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
13 22.00 1221.00 0.00
Other 0 0.00 0.00 0.00
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Total 13 22.00 1221.00 0.00