CMS/EIP Fiscal Report Center: 52
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 100.00 33.33
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 6.00 200.00 33.33
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 32.50 1225.00 37.69
Subtotal (Total Children Is Unduplicated) 28 41.50 1525.00 36.75
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 48 243.00 7290.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 42.00 1260.00 30.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 4000.00 30.00 0.01
Subtotal (Total Children Is Unduplicated) 52 4285.00 8580.00 2.00
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Total 4326.50 10105.00 2.34
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Number of Children (Unduplicated) With at Least One Service 80
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Center 52
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 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
137 4326.50 10105.00 0.00
Other 0 0.00 0.00 0.00
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Total 137 4326.50 10105.00 0.00