CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 9 9.00 499.50 55.50
Subtotal (Total Children Is Unduplicated) 9 9.00 499.50 55.50
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 90.00 4500.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 35.00 1670.00 47.71
OCCT-97530-OT SESSION BY LICENSED OT 3 8.00 543.04 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 7.25 492.13 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 96.25 6533.45 67.88
Subtotal (Total Children Is Unduplicated) 46 236.50 13738.62 58.09
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Total 245.50 14238.12 58.00
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Number of Children (Unduplicated) With at Least One Service 54
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Center 09
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 30 85.75 5150.67 5150.67
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
59 159.75 9087.45 0.00
Other 0 0.00 0.00 0.00
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Total 89 245.50 14238.12 5150.67