CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 3 3.00 166.50 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.50 749.25 55.50
Subtotal (Total Children Is Unduplicated) 11 20.00 1178.25 58.91
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 2.50 125.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 17.50 437.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 27 166.50 8325.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 84.50 4225.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 505.00 252.50 0.50
Subtotal (Total Children Is Unduplicated) 42 778.00 13465.00 17.31
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Total 798.00 14643.25 18.35
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Number of Children (Unduplicated) With at Least One Service 51
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Center 05
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 54 119.00 5873.50 5873.50
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
92 679.00 8769.75 0.00
Other 0 0.00 0.00 0.00
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Total 146 798.00 14643.25 5873.50