CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
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 4 7.50 416.25 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.00 450.00 75.00
Subtotal (Total Children Is Unduplicated) 9 17.50 1127.25 64.41
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 10.00 250.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 19 77.50 3875.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 42.00 2100.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 205.00 102.50 0.50
Subtotal (Total Children Is Unduplicated) 30 334.50 6327.50 18.92
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Total 352.00 7454.75 21.18
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Number of Children (Unduplicated) With at Least One Service 36
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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 33 46.50 2136.00 2136.00
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
82 305.50 5318.75 0.00
Other 0 0.00 0.00 0.00
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Total 115 352.00 7454.75 2136.00