CMS/EIP Fiscal Report Center: 07
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
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.00 225.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 -2.00 -150.00 0.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 8.00 600.00 75.00
Subtotal (Total Children Is Unduplicated) 4 9.00 675.00 75.00
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Total 9.00 675.00 75.00
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Number of Children (Unduplicated) With at Least One Service 4
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Center 07
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 -150.00 -150.00
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
6 11.00 825.00 0.00
Other 0 0.00 0.00 0.00
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Total 7 9.00 675.00 -150.00