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: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 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 6 8.50 637.50 75.00
Subtotal (Total Children Is Unduplicated) 11 20.00 1314.75 65.74
----------------------------------------------------------------------------------------------------------------
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 11 46.00 2300.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 235.00 117.50 0.50
Subtotal (Total Children Is Unduplicated) 32 368.50 6542.50 17.75
----------------------------------------------------------------------------------------------------------------
Total 388.50 7857.25 20.22
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 39
----------------------------------------------------------------------------------------------------------------
Center 05
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 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
87 342.00 5721.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 120 388.50 7857.25 2136.00