CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 10.00 584.25 58.43
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 12 17.50 1107.75 63.30
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 0.50 25.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 64 280.00 14000.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 931.00 465.50 0.50
Subtotal (Total Children Is Unduplicated) 65 1211.50 14490.50 11.96
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Total 1229.00 15598.25 12.69
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Number of Children (Unduplicated) With at Least One Service 72
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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 217 1229.00 15598.25 15598.25
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 217 1229.00 15598.25 15598.25