CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:OTHER
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 4 4.00 222.00 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 10 17.50 971.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
Subtotal (Total Children Is Unduplicated) 18 30.00 1830.75 61.03
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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 15 90.50 4525.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 505.00 252.50 0.50
Subtotal (Total Children Is Unduplicated) 44 784.00 13765.00 17.56
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Total 814.00 15595.75 19.16
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Number of Children (Unduplicated) With at Least One Service 58
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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 56 122.00 6040.00 6040.00
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
100 692.00 9555.75 0.00
Other 0 0.00 0.00 0.00
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Total 156 814.00 15595.75 6040.00