CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 55.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 4.00 222.00 55.50
Subtotal (Total Children Is Unduplicated) 5 5.00 277.50 55.50
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 10.00 678.80 67.88
Subtotal (Total Children Is Unduplicated) 4 10.00 678.80 67.88
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Total 15.00 956.30 63.75
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Number of Children (Unduplicated) With at Least One Service 9
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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 3 8.00 543.04 543.04
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 7.00 413.26 0.00
Other 0 0.00 0.00 0.00
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Total 9 15.00 956.30 543.04