CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:OTHER
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 4 4.00 300.00 75.00
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 6 7.25 362.50 50.00
Subtotal (Total Children Is Unduplicated) 6 7.25 362.50 50.00
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Total 11.25 662.50 58.89
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Number of Children (Unduplicated) With at Least One Service 10
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Center 05
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 13 11.25 662.50 662.50
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 13 11.25 662.50 662.50