CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 11 11.00 610.50 55.50
Subtotal (Total Children Is Unduplicated) 11 11.00 610.50 55.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 61.00 3050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 7.50 509.10 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 1.50 101.82 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 220.75 14984.51 67.88
Subtotal (Total Children Is Unduplicated) 38 290.75 18645.43 64.13
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Total 301.75 19255.93 63.81
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Number of Children (Unduplicated) With at Least One Service 48
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Center 09
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 7 18.50 1202.14 1202.14
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
67 283.25 18053.79 0.00
Other 0 0.00 0.00 0.00
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Total 74 301.75 19255.93 1202.14