CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 29.00 1050.00 36.21
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 50.00 33.33
Subtotal (Total Children Is Unduplicated) 22 34.50 1250.00 36.23
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.50 100.00 40.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 65 272.50 8195.00 30.07
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 48.00 1520.00 31.67
Subtotal (Total Children Is Unduplicated) 68 323.00 9815.00 30.39
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Total 357.50 11065.00 30.95
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Number of Children (Unduplicated) With at Least One Service 90
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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
152 357.50 11065.00 0.00
Other 0 0.00 0.00 0.00
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Total 152 357.50 11065.00 0.00