CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2008 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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 222.00 55.50
Subtotal (Total Children Is Unduplicated) 4 4.00 222.00 55.50
----------------------------------------------------------------------------------------------------------------
Total 4.00 222.00 55.50
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 4
----------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
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
4 4.00 222.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4 4.00 222.00 0.00