CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 42 75.00 4162.50 55.50
Subtotal (Total Children Is Unduplicated) 45 80.00 4440.00 55.50
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 195.00 9750.00 50.00
Subtotal (Total Children Is Unduplicated) 16 195.00 9750.00 50.00
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Total 275.00 14190.00 51.60
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Number of Children (Unduplicated) With at Least One Service 61
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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 1 2.00 111.00 92.50
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
105 273.00 14079.00 0.00
Other 0 0.00 0.00 0.00
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Total 106 275.00 14190.00 92.50