CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:LEA
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 12 12.00 666.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 13 14.00 816.00 58.29
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.00 50.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 15.00 866.00 57.73
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14
----------------------------------------------------------------------------------------------------------------
Center 01
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
1 1.00 50.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 1.00 50.00 0.00
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
12 13.00 716.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 12 13.00 716.00 0.00
Center 52
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
1 15.00 866.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 15.00 866.00 0.00