CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Not Part C
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 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.50 937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 21 32.50 2343.00 72.09
----------------------------------------------------------------------------------------------------------------
Total 32.50 2343.00 72.09
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21
----------------------------------------------------------------------------------------------------------------
Center 09
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
23 32.50 2343.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 23 32.50 2343.00 0.00