CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.00 325.00 54.17
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 32.00 1800.00 56.25
Subtotal (Total Children Is Unduplicated) 26 38.00 2125.00 55.92
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.50 175.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 60 419.50 12615.00 30.07
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 63.00 1800.00 28.57
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.75 186.67 67.88
Subtotal (Total Children Is Unduplicated) 68 488.75 14776.67 30.23
----------------------------------------------------------------------------------------------------------------
Total 526.75 16901.67 32.09
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 94
----------------------------------------------------------------------------------------------------------------
Center 52
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
207 526.75 16901.67 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 207 526.75 16901.67 0.00